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of it. 







t4FK/? Ms-//'.} - * 



D i^ 

Bostoi al Library, 






Harvard College. 



o 



P RA-CTICAL 



OBSERVATIONS 



IN 



SURGER Y, 



ILLUSTRATED WITH CASES, 



BY 

WILLIAM HEY, ESQ. F. R. S. 

MEMBER OF THE ROYAL COLLEGE OF SURGEONS^ IN LOKDON5 

HONORARY MEMBER OF THE ROYAL MEDICAL SOCIETY 

OF EDINBURGH, AND OF THE LITERARY AND 

PHILOSOPHICAL SOCIETY OF MANCHESTER; 

AND SENIOR SURGEON OF THE GENERAL INFIRMARY AT LEEDS. 



LONDON: 

Printed by Luke Hansard, 
FOR T. CADELL, JUN. AND W. DAVIES, IN THE STRAN] 

1803. 




Luke Hansard, Printer, 
Great Turnftile, Lincoln's-Inn Fields. 



PREFACE. 



Soon after I had entered upon the Medical 
Profefiion, I began the cuftom of commit- 
ting to paper fuch cafes, which occurred in 
my practice, as feemed rare, or peculiarly 
infinitive; hoping that the perufal of them 
might affift me in the discrimination and 
cure of difeafes. 

The following Tra&ical Qbfervations are 
chiefly drawn from thefe records. I have 
felefted fuch as appeared to me the moft 
ufeful, and fuch as, I hope, are not altogether 
unworthy the public notice. 

The reader v/ill not find in the following; 
pages many excurfions of fancy, or much 
theoretical reafoning: he muft be content 
with plain fafits, recited in a plain manner. 

The papers have been drawn up amid ft 
frequent interruptions, and fometimes at con- 
fiderable intervals. I have laboured to be 
perfpicuous; though I have often found it 
difficult to defcribe a difeafe, or an opera- 

a 2 tion, 



Yf PREFACE. 

tion, in a manner that fhould clearly convey 
my meaning. 

Where I have happened to differ in opi- 
nion from the authors whom I have quoted, 
I have endeavoured to exprefs my opinion 
in terms that fhould give no offence. I have 
aimed only at truth and utility. 

The advantages of writing hiftories of dif- 
eafes, while they are prefent to our view, 
are fo great, that I would ftrongly recom- 
mend the practice to all who are engaged in 
the medical profeffion, but efpecially to young 
practitioners. The perufal of cafes written 
by one's felf is attended with this advantage, 
that the fenfe of the author is always under- 
ftood : and my own experience leads me 
to obferve, that ufeful deductions may be 
drawn from faithful hiftories, many years 
after they were written, which did not occur 
'at the time of writing. 

Some cafes which I had written, have been 
fuppreffed, as the fubjecls of them have been 
anticipated by other writers. One difeafe 
which I have defcrihed, and to which I have 
ventured to give a name, had not been no- 
ticed by any author, with whole works I 
was acquainted, when I had nearly finifhed 
my paper on that fubj«s#L I find, however, 

that 



PREFACE. V 

that one form of it has been obferved by 
Mr. -Burns, of Glafgow, who has given a 
defcription of it, under the title of fpongoicl 
inflammation. Our conjoined accounts, will, 
I hope, throw confiderable light upon the 
fubje6h . 

It will afford me pleafure if the following 
meets mould be the means of alleviating:, in 
any degree, the diftreffes of the afflicted. 



CONTENTS. 



Cliap. Page. 

I. On Fraclures of the Skull i 

II. On the Cataracl - - - - 35 

III. Of the Strangulated Hernia - - - 119 

IV. Of the Fungus Hismaudes - 233 

V. On Dljlo cation - - - - - 286 

VI. On internal Derangement of the Knee-Joint 327 

VII. On loofe Cartilaginous Suhftances in the "Joints 337 

VIII. On Wounds of the Joints - 349 

IX. Compound Luxation of the Ancle-Joint - 367 

X. On Retention of Urine - - - - 374 

XL On the Cure of the Procidentia Ani in Adults 419 

XII. Of the Cancer of the Penis - 445 

XIII. Convulfions after Strangulation - - 463 

XIV. Of a Tumour in the Neck - 470 
XV. Of the Empyema - 476 

XVI. Of an Enlargement of the Mamma - - 482 

XVlLOfColleclionsofPusintheFagina - - 486 

XVIII. On Alvine Concretions - 490 

XIX. On the Atheroma - 50Q 

XX. On deep-feated Ahfceffes in the Mamma - 504 

XXI. On Amputation - 50S 












Plate II. 
feone which 
; p. 26, 
7^ 

74> 

79> 
141, 

154, 

j6i, 






.^ 



267, 

3°4> 
33 6 - 
378, 
411, 

439> 
462, 

495* 



ERRATA. 

fig. 2. The letter b points out that part of the 
covered the lateral firms, p. 20. 
ine 2, for "or" read "of." 
aft line but one. The h in " had" imperfect. 
. 23, for "peration" read "operation." 
. 3, for "care" read "cure." 
. 24, for "undoubted" read "undoubtedly." 
. 26, for "downards" read " downwards." 
. 7, for « thefe " read « thofe." 
. 3, for "neceffiy" read "neceffity." 
. 12, dele "to." 

8, dele the full point after " ruber." 
, 16, for "Bromfield" read « Bromfeild." 
dele "Cafe" as the catch- word. 

1, for "puois" read "pubis." 
16, for "coa." read "cochl." 
. 21, for " began" read "begun." 

5, for "of" read "by." 

7, for " vomitting " read " vomiting." 



Since the firft chapter was printed ofF, I have ufed fome 
faws made by an ingenious mechanic in Leeds, which 
worked with more eafe than any I had ufed before. They 
were made very thin, and the teeth were a little fet ojfYiks 
the teeth of common faws. 



t I ] 



C HAP. 




I 



On Fractures of the Skull. 

T mud appear evident to every one, who 
coniiders the great advantages which we 
receive from thofe ftrong coverings, with 
which our all-wife Creator has furrounded the 
brain, that no portion of them ought to be 
removed, in the treatment of injuries of the 
head from external violence, unlefs fuch re- ■ 
moval is neceflary for the cure of the patient. 

That excellent fargeon, the late Mr. Pott ? 
ftrenuoufly recommended the exciiion of a, 
circular portion of the fcalp, in all cafes where 
the application of the trephine became ne- 
ceflary; and as the opinion of fuch an author 
muft have great weight in fettling the practice 
in thefe cafes, I {hall examine the grounds of 
this opinion, being perfuaded that it is rarely, 
if ever, neceflary to remove any portion of the 
fcalp, while it remains in a found ftate. 

B In 



2 On Fractures of the Sktjll 

In Mr. Pott's works* we find the following 
directions t "' If the integuments are not 
" wounded, or if the wound made in them be 
" fo fmall as not to admit a proper examina-- 
" tion of the bone, and the circumftances of 
" the cafe are fuch as render fuch inquiry ne- 
" ceflary, a portion of the fcalp mould be re- 
" moved. The manner of doing this has for- 
6i merly been the occafion of much difference 
* 4 of opinion; but there can be no doubt 
u about the greater propriety of removing a 
* fi piece of the fcalp for this purpofe, by an 
^ incifion in a circular form, it being that 
&i form which niuft afford the cleared view. 
" If there be no wound, the point ftricken 
* 4 mould be made the centre of the incifion * 
" if there be a wound, fuch wound mould be 
&i made the centre of the piece to be removed ; 
66 and fuch piece mould always be of fize fuf* 
<e ficient to render the application of the tre- 
u phine eafy." 

Let us now examine the practice here re- 
commended. If the fcalp is not wounded, or 
the wound is fmall, it is impofiible to know 
the extent of the fracture, or the place where 
the trephine may be applied with the greateft 
advantage. Allowing therefore, for argu* 

# Vol. L p. 157. o&. ed, 

nient's 



On Fractures of the Skull. 8 

ment's fake, that it is neceffary to remove a 
portion of the fcalp for the purpofe of apply- 
ing the trephine ; it is impoffible to know, till 
the courfe and extent of the frafture have been 
afcertainecl, in what place this circular incifion 
of the integuments is to be made. But when 
the extent of the frafture has been afcertain- 
ed, by a fimple incifion of the integuments, 
made along the courfe of the fra£lure, the re- 
moval of a circular portion of the fcalp be- 
comes unneceffary. For if the fra6ture and 
confequent incifion are extenfive, a gentle fe- 
paration of the divided parts will afford ample 
room for the application of the trephine. If 
the fracture is of fmall extent, a crucial divi- 
fion of the fcalp will be fuflicient for that pur- 
pofe. 

I have a farther objeftion to the method 
propofed by Mr. Pott. I confider it not only 
as unneceffary, but injurious. For, fuppofing 
a circular portion of the fcalp to be removed 
where the trephine is applied, there will then 
remain nothing to cover the dura mater, when 
the wound is healed, but a tender cicatrix ; 
whereas, if the integuments (except the peri- 
cranium) had been preferred whole in that 
part, they would in fome meafure have fup-- 
plied the lofs of bone, and would have af- 

B 2 forded 



4 On Fractures of the SiivLt. 

forded in future a confiderable degree of 
protection to the brain, which by the remo- 
val of the cranium is unavoidably expofed to 
danger. 

I coniider the preformation of the fcalp as d 
material advantage to a patient who has fuf- 
fered a frafture of the fkull ; not only with, 
relation to the benefit which that natural co- 
vering of the brain mav afterwards afford him* 
but alfo with relation to the effeft which fuch 
prefervation has in expediting the care. In 
many cafes, the fcalp may be applied imme- 
diately to the cranium and dura mater, after 
the removal of fuch part of the bone as is ne~ 
ceffary to be removed : and where the imme- 
diate application is improper, the fcalp may 
be kept feparate for a time, without injury to 
the patient, till the parts underneath it are 
"brought into fuch a ftate as will admit a re- 



union. 



If the excifion of a portion of the fcalp be 
confidered as necefiary, when a fmgle appli- 
cation of the trephine is to be made ; for the 
fame reafon fuch excifion muft be repeated, or 
enlarged, wlien the extent of the fracture re- 
quires a repeated application of that inftru- 
ment. It is eafy to conceive what a de varia- 
tion of the fcalp muft be made in a very ex- 

teniive 



On Fractures of the Skull. 5 

tenfive fracture, by a furgeon who conducts 
himfelf agreeably to this doctrine. The late 
Mr. Gooch, who was an excellent furgeon, 
applied the trephine thirteen times in one 
cafe, and for that purpofe removed the whole 
portion of fcalp covering the fraftured part of 
the cranium. An infpeclion of the Plate, in 
which this fracture is reprefented, is fufficient 
to convince any experienced furgeon how te- 
dious the cure niuft have been, and how great- 
ly the patient would have been benefited by 
the prefervation of the fcalp, if fuch preferva- 
tion had been practicable. 

It is well known by every experienced fur- 
geon, that the exiftence of a fraclure cannot 
always be afcertained till the cranium is ex- 
pofed to view. Suppofe then a furgeon called 
to a patient labouring under the ufual fymp- 
toms of a fraclure of the fkull, where there is 
no wound, nor inequality in the furface of the 
cranium, to be perceived ; how is he to act in 
fuch a cafe ? According to the directions 
given by Mr. Pott, it feems that he ought to 
make a circular excifion of the fcalp, where the 
injury has been received, for the purpofe of 
afcertainino; the exiftence of a fraclure, " If 
" there be no w T ound, the point ftricken 
u ftio.uld be made the centre of the incilion," 

B 3 I am 



6 Oil Fractures of the Skull, 

I am certain, however, that the furgeon 
whofe practice is conformable to this direc- 
tion, muft not unfrequently have reafon to 
cenfure the temerity of his own condu6t, in de- 
priving a patient, without neceffity, of a por- 
tion of fcalp, where a Ample incifioii only was 
needful. 

I had occafion, when I was a young man, 
to witnefs an error of this kind in a furgeon 
whofe abilities I refpefted. A circular por- 
tion of the fcalp was removed, under the ex- 
pectation of finding a fra6lure of the cranium, 
to the mutual regret of the furgeon and pa- 
tient, as a tedious dreffing. of an unneceffary 
wound was the confequence. This circum- 
ftance ftruck me forcibly, and led me to ufe 
great caution in removing any portion of the 
fcalp without an indubitable neceffity. 

If an unneceffary removal of the fcalp 
ought to be avoided in the treatment of frac- 
tures of the flail, it is of ftill greater import- 
ance to preferve every portion of the cranium, 
which the fafety of the patient does not com- 
pel us to remove. 

The only inftrument now in general ufe 5 
for fawing out any portion of the cranium, is 
the trephine, or trepan. I fpeak of thefe as 
one* as they differ. only in the manner of 

. working, 



On Fkactures of the Skull. f 

working. The ufe of this inftrument caufes 
an unneceffary deitrufilion of the cranium, and 
in other refpe&s is attended with inconve- 
nience. The piece of bone fa wed out by the 
trephine mult be of one figure, whatever be 
the form of the fracture ; and the quantity of 
bone removed mull be generally greater 
(fometimes confiderably greater) than the cafe 
requires. 

The purpofes for which any portion of the 
cranium is removed are, to enable the furgeon 
to extra6l broken fragments of bone, to ele- 
vate what is depreffed, and to afford a pro- 
per iffue to blood or matter that is, or may 
be, confined. I will conlider each of thefe 
purpofes with refpeft to the application of the 
trephine 

When a broken fragment of bone is driven 
beneath the found contiguous part of the cra- 
nium, it frequently happens, that the extrac- 
tion cannot be executed without removing 
fome of the unbroken part, under which the 
fragment is depreffed. This might generally 
be effected with very little lofs of ibund bone, 
if a narrow portion of that which lies over the 
broken fragment could be removed. But 
fuch a portion cannot be removed by the tre- 
phine. This inftrument can onlv faw out a 

B 4 circular 



S On Fractures of the :' Skull. 

circular piece. And as, in executing this, the 
central pin of the faw muft be placed upon the 
uninjured bone, it is evident, that a portion of 
the found bone, greater than half the area of 
the trephine, muft be removed at every ope- 
ration. When the broken and depreffed frag- 
ment is large, a repeated application of the 
trephine is often neceffary, and a great de- 
finition of found bone muft be the confe- 
quence. 

"W hen the injury confifts merely of a fiffure 
with depreffion, a fmall enlargement of the 
fiffure would enable the furgeon to introduce 
the point of the elevator, fo as to raife the de- 
preffed bone. But a fmall enlargement of the 
fiffure cannot be made with the trephine. 
When it is neceffary to apply the elevator to 
different parts of the depreffed bone, a great 
deal of the found cranium muft be removed, 
where a very narrow aperture would have been 
fufficient. 

The fame reafoning will apply to the cafe 
of openings made for the purpofe of giving a 
difcharge to extravafated blood, or matter. 

If a faw could be contrived, which might 
be worked with fafety in a ftraight, or gently 
curvilineal direction, it would be a great ac- 
quifi'tion to the practical furgeon. Such a faw 

I can 



Face Page p. 



PL.l. 




On Fractures of the Skull. 9 

I can now with confidence recommend, after 
a trial of twenty years, during which time I 
have rarely u fed the trephine in fractures of 
the fkull. Its ufe has been adopted by my 
colleagues at the General Infirmary in Leeds ; 
and will be adopted, I ihould hope, by every 
furgeon who has once made trial of it. 

It was firft lhewn to me by Mr. (now Dr.) 
Cockell, an ingenious practitioner at Ponte- 
fract, to whom the public is indebted for the 
clifcovery, or revival, of this excellent inftru- 
ment. A faw, formed on the fame principle, 
is reprefented in Scultetus's Armamentarium 
chirurgicum; but I understood Dr. Cockell to 
fay, that the inftrument which he fhewed me 
was of his own invention, and that he had ufed 
it with great advantage ill extenfive fractures 
of the fkull. Dr. CockelFs faw had a femi- 
circular edge, as reprefented in the annexed 
Plate*, where the fize of the figure is two-thirds 
of the real ctimenfions of the inftrument. But 
the edge may be made ftraight, (as is fhewn in 
the Plate) or of any degree of convexity which 
may be thought moil ufeful. The ftraight 
edged faw executes its talk with greater readi- 
nefs ; but the convex edge is neceflary when 
the bone is to be fawed in a curvilineal direc- 

* Plate I. . 

tion. 



K> On Fractures of the Skull, 

tion *. It is alfo ufeful when the thicknefs of 
that part of the cranium which is to be fawed 
out is very unequal. 

This instrument is worked with eafe 9 if the 
preffure made upon it by the hand is light. 
It faves much time in cafes of extenfive frac^ 
ture, where the repeated application of a tre«* 
phine would have been needful; and it may 
be ufed with lefs danger of wounding the dura 
mater, if the fame precautions are ufed, in ex- 
amining from time to time the depth of the 
groove, as is neceflary in the ufe of the tre^ 
phine. 

I mall not enter at large upon the treats 
ment of injuries done to the head by external 
violence; but mall refer my reader to the 
many excellent treatifes and obfervations 
which have been already publifhed on that 
fubjecl. I mall only give a fliort iketch of 
my own practice, as far as relates to the pre-? 
fervatiori of the fcalp and cranium. 

* The.faws here reprefented were made by Mr. Sa- 
vigny, in London. Thole with a ftraight edge are drawn 
the real iize of the infcrument, and were ordered by my 
colleagues at the General Infirmary^ MeiTrs. Logan and 
Chorlej*. It has been fuggeited to me by an ingenious 
friend, that the edge of the faw ought to be fomewhat 
thicker than the remaining part., that it may work more 
eafily in the*groove. 

When 



On Fractures of the Skull. 1 1 

When I am called to a patient labouring 
under the fymptoms of a fractured ikull, if I 
find no wound in the fcalp, upon examining 
the head when fhaved, I make an incilion 
through the fcalp in the part where a fracture 
is moft to be fufpected. If no fracture 
appears, I take fo much blood from the 
divided arteries, as the ftate of the patient 
feems to require, and then unite the lips of 
the wound. 

If the bone is fractured, I enlarge the 
wound by a fimple inciiion along the courfe 
of the fracture, tracing the fiffure, or fiffures, 
through their whole extent, unlefs they are 
continued to the balls of the ikull, or where 
their limits cannot be explored. I do this 
either by cutting carefully upon the fiffure, if 
it is fmall; or, if it is wide, and the pericranium 
much feparated, by placing the back of my 
knife upon the fiffure, and flitting open the 
integuments, as the courfe of the fracture 
directs. Having thus expofed the whole ex- 
tent of the fracture, avoiding all unneceffary 
detaching of the pericranium; and having 
obferved what is neceffary to be done, for 
removing broken fragments, raifmg depreffed 
bone, or giving iffue to confined matter; I faw 

off 



12 On Fractures of the Skull, 

off fuch pieces of the cranium as require to be 
removed, while the integuments are held back 
by the affiftants* 

The line, in which the faw is to be moved, 
is firft marked out by drawing it gently along 
the bone in. the proper direction; or the fur- 
geon may fix the courfe of the groove, by 
placing the nail of his thumb or fingers upon 
the cranium, as a guide to the faw. It happens 
not unfrequently that the fiflure itfelf may be 
made the groove in which the faw is worked ; 
and in this cafe no more bone is removed 
than that wjiich the injury done to the head 
has rendered ufelefs, as in the following cafe ; 

CASE I, 

In 1 78 1 , a fon of Mr. Cliriftopher Topham s 

of Leeds, aged fourteen years, received a blow 

upon his head, from a piece of brick thrown at 

him. He vomited frequently on the two firft 

days after the accident, and then retained 

his food. His parents, not apprehenfive of 

the real nature of the injury, did not fend for 

me till the fourth dav after the accident. He 

had then a confide rable degree of fever, but 

was ftill able to walk about, his room, though 

fome portions of the brain were lying amonglt 

the hair. 

Upon 



On Fractures of the Skull. 1 3 

Upon examination, I found a fra£fcure of 
the right parietal bone, of an oval figure, two 
inches and a quarter in length, and an inch 
and half at its greateft breadth. To this ex- 
tent the bone was depreiTed, but not feparated 
from the contiguous part of the cranium. 
Near the middle of the fra&ured part, where 
the depreffion was the greateft, there was a 
hole, and there the broken edges of the bone 
had pierced the dura mater, and wounded the 
brain. The bone was not depreffed beyond 
the extent of the fra6lure. With* the convex- 
edged faw I took out the depreffed bone, bv 
making the exterior fiffure to be the groove in 
which the faw was worked, without the lofs of 
any portion of uninjured bone, except a very 
fmall part at each extremity of the fracture, 
where it was neceffary to bring the grooves 
to appoint*. The removal of the depreffed 
bone in this cafe would probably have re- 
quired the application of a trephine at four 
places. 

The fuperiority of an inftrument, which will 
enable the fargeon to remove fuch a piece of 
bone, without any other lofs to the patient, 
than of the part rendered ufelefs by the in- 

* See Plate II. Fig. 1, 

J ur JV 



14 On FRACTURES of the SKtlLIr. 

jury, muft be obvious to every one. The 
time taken up by the operation was alfo con- 
siderably fhortened, and left danger of wound- 
ing the dura mater was, in my opinion, in- 
curred* 

A fungus, about the fize of a large nutmegs 
arofe from the brain, and had a ftrong pulfa- 
tion- I made no preffure on the fungus, but 
only applied mild dremngs, generally dry 
lint. At the end of three weeks the fungus 
was reduced nearly to a level with the reft of 
the wound, which then healed fpeedily. 

In extenlive fractures, where a long portion 
of bone is depreffed, the advantages arifing 
from the ufe of this inftrument require no 
laboured comment. The following cafe will 
make them fufficiently manifeft- 

CASE II, 

In 1 784, 1 was fent for to Garforth, a village 
about feven miles from Leeds, to the fon of a 
collier, aged thirteen years, who had fuffered a 
fra6lure of the fkull, from the fall of a coal in 
the lhaft of a coal-pit. The boy had vomited 
frequently, but continued fenfible. There 
was a contufed wound on the left fide of his 
3 head* 



On Fractubes of the Skull. 15 

head, about three inches in length. I enlarged 
this wound, and traced the fracture through 
its whole extent. It began in the frontal 
bone, a little above the temporal mufcle; 
croffed the coronal future at right angles, 
running obliquely backwards and downwards, 
acrofs the left parietal bone, to the occipital 
future a little above the maftoid procefs. On 
the anterior part of the parietal bone the frac- 
ture was broad, and feveral broken pieces 
were depreffed. In the remaining part, the 
fifiure was wide ; but the cranium remained at 
its due level. In my notes, made during my 
attendance on this patient, I find it remarked, 
that it would have required eight or nine pe£~ 
forations of the trephine, in order to remove 
the depreffed pieces, and enlarge the fiffure ; 
whereas I was able to take out all the depref- 
fed pieces, without applying the faw beyond 
the breadth of the fracture, except where I 
thought it proper to enlarge the fifiure a little ; 
and this was effected by a longitudinal divifion 
of the bone on one fide of the fiffure. 

The dura mater was found covered with 
coagulated blocd where the bone was broken 
into fragments. Beneath the poiterior part 
of the fracture, where there was merely a 
gaping fifiure, without depreffion of the cra- 
nium. 



15 On Fractuees of the Skull. 

ilium, I found a lacerated wound of the dura 
mater, two inches in length. 

I did not remove any portion of fcalp in 
this operation. 

An oblong fungus arofe through the aper- 
ture in the dura mater ; but with fimple dref- 
lings, without preffure, the fungus retired as 
the cicatrization advanced, and the boy got 
well, without having loft any portion of the 
fcalp, or any part of the cranium, except 
the broken fragments, and a narrow ftrip 
of bone which lay over the wound of the dura 
mater. 

My ufual method of dreffing after the ope- 
ration has been, to cover the dura mater with 
lint, and to lay down the flap of fcalp upon 
the lint, till granulations have arifen from the 
dura mater, and filled up the cavity made by 
the lofs of bone. I have then placed the flap 
in immediate contafit with the inferior, granu- 
lations, and fupporting it with plafters, have 
thereby promoted a fpeedy union of the parts. 
But fmce Mr. Mynors of Birmingham, pub- 
liihed a cafe, in which he laid down the fcalp 
upon the dura mater, without any intervening 
dreffings, I have feveral times, in favourable 
cafes, followed this method with advantage, 
and have even united the divided integuments 

by 



On Fractures of the Skull, ly 

by ftitches of the interrupted future. But 
this method is not proper in ail cafes. Where 
the dura mater is lacerated, and portions of 
the brain are coming away, it mult evidently 
do mifchief. So alio in fractures, where the 
termination cannot be afcertained, I. fhould 
decline fuch a practice. 

When I have attempted to bring about the 
adhefive procefs in the firft inftance, I have 
not been able to prevent fome degree of fup- 
puration, but if the wound had a depending 
orifice, the matter efcaped between the 
ftitches, and the divided fcalp healed with a 
very narrow cicatrix. When the orifice of 
the wound has not been favourable for the 
ifiue of the purulent matter, an abfcefs has 
fometimes formed near the fra&ure, and has 
required an incifion of the integuments. But 
this is a much lefs inconvenience than that of 
leaving the dura mater uncovered by the 
fcalp, when it had loft its natural covexki'g^^f 5-- 
bone. Moftof the cafes, in which I have Med 
Mr. Mynors's method, have been fractures of 
the os frontis. 

The following cafe affords an inftance of 
the fafety and advantage of this method.- 

C CASE 



18 On Fractures of the Skull. 

CASE III. 

Auguft 9th, 1800. I was called to the fori 
of Thomas Wood of Birftal, aged ten years, 
who, by falling into a ftone quarry the pre- 
ceding evening, had fractured his fkull. He 
had remained infenfible fince the accident. 

There were two tranfverfe fiffures in the 
Tipper part of the os frontis^ on the left fide. 
One of them was between two and three in- 
ches in length ; the other was morter. Juft 
above thefe fiffures, the bone was depreffed 
tranfverfely about two inches, as if it had 
been (truck with the edge of a ftone. The 
bone was not broken where it was depreffed, 
but was driven inwards, fo as to form at the 
bottom a narrow furrow, or groove. "With 
the ftraight-edged faw I cut through the bone 
a"t the bottom of the furrow, and alfo at the 
loweft fiflfiire. I took away the intermediate 
bone, and then raifed that portion of the cra- 
nium, above the furrow, which yet remained 
depreffed. The dura mater was not injured. 
I drew together the integuments, and united 
them by the interrupted future. 

The boy was delirious and reftlefs, frequent- 
ly fhouting during the operation. He had 
been bled by Mr. Booth, the furgeon who 
6 . , was 



To FaceJ'cu/s 19. 



Flu. 2. 



4 




3 



On Fractures of the Skull. 19 

was attending him* I direcled a purgative 
to be given* and the faline draughts after its 
operation* I advifed the application of a 
blifter to his head, with bleeding by leeches, 
if the delirium mould continue % 

11th. He was much better, but had not 
regained his underftanding completely, He 
was more calm, and could give a rational an- 
fwer fometimes to the inquiries made of him. 

I did not vilit him again, but was informed 
by his furgeon, that he foon regained his un* 
derftanding, and was able on the 10th day 
after the operation to walk from his father s 
houfe, which was a public one, to that of a 
neighbour, to avoid the noife of a large com- 
pany. 

The wound was healed on the 26'th day 
after the operation. 

Fig. 1 . in Plate II. reprefents that portion 
of the parietal bone, which was removed by 
the circular faw, in the fir ft of the preceding 
cafes. This fractured portion was confider- 
ably depreffed from its circumference, where 
it remained attached to the found part of the 
parietal bone. It was fiffured alfo in various 
directions, and had a hole formed in it near 
its middle, where the letter a is placed. Be- 
fore the drawing was taken, (which is a mere 

* Thefe means were not ufed. 

c % outline 



20 On Fractures of the Skull, 

outline) the bone was reduced to a flat ftate 
by preffure. An infpe&ion of the figure will 
fufficiently demonftrate the great advantage 
of an inftrument, which could remove fuch a 
broken piece of bone, ftill adhering firmly at 
its circumference to the found part, without 
any lofs of found bone, except a very fmall 
part at each extremity of the fra&ured por- 
tion. As it was neceflary to bring the 
grooves, in which the faw moved, to a point, 
at each extremity of the fraflured portion, the 
lofs of a minute quantity of found bone was 
unavoidable ; but this was trifling, compared 
with the quantity deftroyed at every opera- 
tion, by the ufe of the trephine. 

Fig. 2. Reprefents the edge of a portion of 
the os occipitis, which it was neceflary to re^ 
move in an extenfive frafture of that bone, 
that pafled acrofs one of the lateral finufes. 

Not to enlarge at prefent upon the impof- 
Ability of removing fo long a piece of bone 
with the trephine, without deilroying a great 
deal of found cranium, by the frequent appli- 
1 cation of that inftrument, I {hall only remark, 
that the annexed figure ihews how difficult it 
would have been to faw out fo unequal a piece 
f| of bone with the trephine, without injuring 
the dura mater. By means of the faws above 

reprefented. 



V? 



V 

o 






On Fractures of the Skull. 21 

reprefented, I took out this piece without the 
leaft injury to the lateral firms. I ufed the 
ftraight laws till I had got through the thin- 
ner parts of the bone, and then divided the 
thick parts by means of the convex-edged 
law, which will fafely divide a narrow ridge of 
bone, as it does but touch the part with two - 
or three teeth at once. 

Though this inftrument is principally ufeful 
in fractures of the fkull, yet its ufe is not con- 
fined to fuch cafes. It may be applied for the 
removal of bone under fuch circumftances as 
will not admit the ufe of a common faw. I 
found it to be a convenient inftrument in one 
of the following cafes of caries in the tibia, 
and have annexed two figures of the piece of 
bone, which it enabled me to remove, for the 
purpofe of exploring a deep feated caries in 
the tibia of a young lady, whofe cafe I mail 
relate. 

Fig. 3. and 4. give an exterior and interior 
view of the wedge of bone, which was fawn out 
of the tibia of the young lady, whofe cafe is 
related in the next article. 



c 3 4 Abscess 



[ 22 ] 



Abscess in the Tibia with Caries, 

CASE I. 

TOWARDS the conclufion of the year 
1786, a young lady from Richmond, in 
Yorkfliire, confulted me, on account of a fmall 
tumour in the anterior and middle part of the 
tibia. It had exactly the appearance of a 
common node ; and had fuch a degree of foft- 
nefs in its centre, that I apprehended a fmall 
quantity of fluid was contained in it ; though 
that could not, from the thicknefs of the 
pcriofteum, be diftinclly felt. The account 
which flie gave me of her diforder was as 
follows : 

In the preceding May me had a fever, 
which continued about four weeks ; at the 
expiration of which, a violent pain began to 
affect her leg. The pain continued without 
intermiffion during fix weeks, and then abated 
upon the appearance of a fmall tumour on the 
fhin. She could then walk about with little 
or no uneafmefs : but fneezing or coughing 
caufed a painful fenfation in the tumour, She 
was, in other reipects, in perfect health, 

J recom*- 



Abscess in the Tibia. 23 

I recommended the trial of fome means to 
effefit the difperfion of the tumour ; and with 
this view I dire&ed Plummets pill, with the 
decoftion of Mezereon, and applied mercu- 
rial ointment to the part, covering the tu- 
mour, in the intervals of this application, with 
ceratum faponis. By the ufe of thefe means 
the tumour became lefs, and the unealinefs 
was diminiihed ; fo that the young lady 
thought herfelf nearly well. But before the 
expiration of winter the tumour began again 
to increafe in bulk ; and in the fummer 1787, 
fhe returned to Leeds to put herfelf intirely 
under my care. 

The tumour was then larger and fofter, and 
there remained not the leaft hope of curing 
my patient without difcharging the matter, 
and afterwards treating the cafe as the ft ate of 
the periofteum and tibia might require. 

Upon laying open the tumour, I found the 
periofteum difeafed, and thickened ; feparated 
from the tibia, and including a fmall quantity 
of purulent matter. The furface of the tibia 
was rough, as far as the matter had covered 
it ; and in the centre of the rough part there 
was a hole equal in bore to a goofe's quill, 
which penetrated the bone in a direfit line 
about a quarter of an inch. 

c 4 As 



24 Abscess in the Tibia. 

As the bone was firm in the rough part, and 
refifted the preffure of a probe, I thought it 
right to try whether the furface, upon expofure 
to the air, would not produce good granula- 
tions ; and, therefore, after removing fo much 
of the periofteum as I found in a morbid ftate, 
I dreffed the wound fimply. 

Upon continuing this treatment about a 
fortnight, I became fenfible, that more matter 
iffued from the wound than the furface of it 
ought to have produced. Sufpe&ing that the 
hole above mentioned might lead to fome 
cavity in the bone, I plugged it up with lint, 
and found, on removing the plug the next day 9 
that more purulenl matter flowed out than the 
perpendicular cavity of the bone could con- 
tain. I made an examination with a bent 
probe, and difcovered a horizontal cavity con- 
nected with the perpendicular one, and run- 
ning both upwards and downwards in the lon- 
gitudinal direction of the bone. It was now 
clear that the bone was affefited with an in- 
ternal caries ; but it was impoffible to afcer- 
tain the extent of the caries by fuch an exa- 
mination. 

Nothing now remained to be done, which 
could afford a rational hope of curing this 
difeafe, except amputation of the limb 5 or a 

, . bold 



Abscess in the Tibia. 25 

bold attempt to explore fully the extent of 
the internal caries, and to remove the difeafed 
part of the bone. I explained the cafe fully 
to my patient, who fiibmitted intirely to my 
judgment the means to be ufed for her re- 
covery. She had apparently a good conftitu- 
tion ; and, excepting the caries of the bone, 
was in perfect health. I determined there- 
fore to avoid, if it were pofiible, disfiguring 
this young lady by an amputation. I was fa- 
tisfied that me would not reproach me on 
account of my ineffectual endeavours to pre- 
ferve her limb, if my attempt to remove the 
difeafed part of the bone ihould prove unfuc- 
cefsfuL 

I began the operation by differing off the, 
granulations of flefti which had arifen from 
the bone, and then fa wed out, by means of a 
circular headed faw, a wedge of the tibia two 
inches in length, which I had previoufly 
marked at each extremity of the longitudinal 
cavity in the bone. This wedge was half an 
inch in breadth, and a quarter of an inch in 
thickneis, and coniifted intirely of the lami- 
nated part of the bone. The removal of this 
portion of the tibia brought to view a caries of 
the cancelli almoft as exteniive as the length 
-pf the piece which I had fa wed out. With 

4. 

different 



26' Abscess in the Tibia. 

different trephines, fuited to the breadth of 
the caries, I removed the difeafed cancelli or 
the bone quite through to the oppofite la- 
mella, as this part of the bone was carious 
throughout its whole thicknefs. 

As the caries extended itfelf in various di- 
rections, it was not poffible to remove the 
whole of it with a trephine, without removing 
alfo a large portion of the found part of the 
bone. But this I wifhed to avoid as much as 
poffible. By the affiftance therefore of a 
itrong {harp pointed knife, I purfued the 
caries in every direction, until I had removed 
every part which had an unfound appearance. 

This operation took up more than two 
hours ; yet the young lady bore it with the 
utmoft patience and fortitude. I dreffed the 
cavity in the bone, and the reft of the wound, 
with dry lint, in the moil fimple manner. 
The whole furface was fpeedily filled with 
good granulations, and a complete cure was 
obtained without any exfoliation. 

The limb which was difeafed has now T as 
much ftrength as the other ; and no uneafi- 
nefs is produced even by violent exercife* 



REMARKS. 



Abscess in the Tibia. 27 

REMARKS. 

Upon a review of this cafe, I am inclined 
to think, that an abfcefs was formed within 
the tibia in confequence of the fever which 
me had in May 1786. During the conti- 
nuance of the fever, fhe had no particular 
pain in her leg ; but upon the decline of the 
fever the pain commenced, and continued 
violent for fix weeks. It feems moil probable, 
that during this time the matter was making 
its way through the anterior lamella of the 
tibia, and that the pain abated foon after the 
matter had perforated the bone ; for it ceafed 
immediately upon the appearance of a tu^ 
mour on the fhin. It is furprifing that fuch 
a perforation mould have been made through 
fo firm a part of the bone, without any exten- 
five caries in the lamella ; efpecially as the 
lamellated part of the tibia was remarkably 
firm and thick. The perforation appeared as 
if it had been made with a gimlet. The pain 
was fo great during this operation of nature, 
that my patient affured me, and that imme- 
diately after the removal of the carious part 
of the bone, that fhe had fuffered more pain 
during the whole of the fix weeks above men- 
tioned, 



28 Abscess in the Tibia. 

tioned, unlefs when fhe was afleep, than I had 

caufed during the operation neceflary for re- 



moving the unfound bone. 



CASE II. 

Hannah Croft, a ftout young woman, aged 
fifteen, was admitted an in-patient of the Ge- 
neral Infirmary at Leeds, in the beginniug of 
the year 1792. She had a fcabby eruption 
on one of her hips, and a fmall ulcer in the 
leg. As the ulcer fhewed no granulations of 
flefh,yel difcharged daily a quantity of puru- 
lent matter, I examined it with a probe, and 
found that the bone was carious beneath. 
Upon preffing the integuments, which fur- 
rounded the ulcer, againft the tibia, I could 
diftin&ly feel a roughnefs in the bone, extend- 
ing to the breadth of a milling, with a depref- 
iion in the middle of the rough part. I di- 
vided the integuments as far as this roughnefs 
extended, and found a circular portion of the 
tibia to be carious, and to have a hole in the 
middle of it, out of which iffued purulent 
matter. The patient had felt very little pain 
in her leg previously to her admiffion into the 
Infirmary; and when firft admitted took little 
notice of the ulcer in her leg. 

I thought 



Abscess in the Tibia. 29 

I thought it advifable to treat this pa- 
tient in the manner which had proved fo 
fuccefsful in the preceding cafe ; and, hav- 
ing divided the integuments upwards apd 
downwards, until the whole of the caries was 
expofed, I proceeded to remove the difeafed 
parts of the bone. 

I flrft took away the central part, where 
the abfcefs was formed in the tibia, by the 
help of a trephine. The lamellated part of 
the bone, furrounding the hole out of which 
the matter chiefly iffued, was in this cafe ca- 
rious ; but the difeafe did not run deep into 
the cancelli of the bone. Above and below 
this central part, the caries feemed to be in- 
tirely confined to the lamella, and extended, 
in the whole, about fix inches. After fawing 
out, with the trephine, the part, principally af- 
fected; I removed the reft of the caries with 
lharp gouges, cutting off every portion of bone 
which had a morbid appearance. 

The operation was tedious, but amply re- 
paid my patient for the pain which it gave 
her, by the prefervation of her limb. The 
difeafed parts of the bone were fo completely 
removed, that there was not the leaft exfo- 
liation during the progrefs of the cure ; and 

the 



30 Abscess in the Tibia. 

the wound was intirely cicatrized at the ex* 
piration of ten weeks. 

Meffrs. Lucas and Logan attended, and 
gave me their affiftance at the operation. 

I have treated ibme other cafes of caries in 
the tibia in the fame manner, and with equal 
fuccefs. Where the extent of the caries is 
not fo great as to prevent a complete removal 
of the morbid part, this method is extremely 
ufeful, and far fuperior to the ufe of the po- 
tential or a&ual cautery. 

The trephine is not wanted where the can- 
eelli of the bone are not affected with the 
caries. The difeafed parts of the lamella may 
be removed with gouges, or fmall chiffels. 
Granulations of flelh will then arife from the 
found parts of the bone, and become united 
with the integuments, which ought to be pre- 
ferved as far as is poffible. 



[ 31 ] 



A Wound of the pojterior Tibial Artery. 

AS the faws above defcribed were found to 
be extremely ufeful in this cafe, and as the 
operation, by which the cure was effected 
without amputation of the limb, was never 
before performed within the compafs of my 
knowledge, I mall relate the particulars of the 
cafe, though the patient did not come imme- 
diately under my own care. 

June 22d, 1801. John Appleyard, a collier, 
aged fifty-four years, was admitted an in-patient 
of the Leeds Infirmary, under the care of Mr, 
Logan, on account of a wound in his leg, made 
with a fharp pick-ax, the 1 5th inftant. The 
wound had bled violently at the firft, but the 
haemorrhage ceafed in a fhort time, and did 
not return till near the expiration of a week, 
Mr. Logan was then defired to vifit the poor 
man at his own houfe ; but the haemorrhage, 
though it had been again violent, had ceafed 
before his arrival. 

Mr. Logan, finding that the pick-ax had 
paffed into the mans leg between the tibia 
and fibula, and had made a deep wound, in 
which, without dilatation, the bleeding veffel 

could 



32 WOUND OP THE 

could not be difcovered, recommended a re- 
moval of the patient to the General Infir- 
mary. 

24th- I faw the patient with Mr. Logan. 
The wound was then plugged up by pieces of 
fpunge, which the houfe apothecary had 
applied, upon an appearance of returning 
haemorrhage. There was at this time no 
bleeding; and the leg being in an inflamed 
ftate, we judged it bell to apply a mild poul- 
tice, and to defer an enlargement of the wound 
till the inflammation mould have ceafed. . 

July lft. The haemorrhage returned, but 
was immediately checked by the application 
of a tourniquet. Mr. Logan called a conful- 
tation of the furgeons, and as the inflamma- 
tion of the leg had now ceafed, it was deter- 
mined to make an attempt to fecure the bleed- 
ing vefiel. After the removal of the fpunge, 
the wound was carefully examined. It ad- 
mitted a finger to pafs readily behind the 
fibula to the fide of the tendo Achillis, at which 
place the wound approached near the fkin. As 
it was impoffible to difcover the wounded vef- 
fel through the orifice at which the pick-ax 
had entered, it was thought proper to make a 
wound on the back part of the leg by the fide 
©f the tendo Achillis, where the integuments 

felt 



Of the Tibial Artery. 33 

felt thin. Upon flackening the tourniquet, 
the blood gullied out at both the wounds, and 
appeared lo clearly to flow from a veffel 
deeply feated behind the fibula, that there 
feemed to be up hope of difcovering and 
fecurino; the veffel by means of an incifion 
made on either lide of the fibula. In this 
dilemma it occurred to me, that the late Mr. 
Gooch had propofecl the removal of a portion 
of the fibula, in fueh a cafe as the prefent, to 
prevent the neceffity of amputating the limb. 
I mentioned this thought to my colleagues, 
who approved of the propofal, and the ope- 
ration was immediately performed by Mr. 
Logan. 

After making a proper divifion of the inte- 
guments, the peronaei mufcles were feparated 
from the bone fufnciently to admit of the re- 
moval of a piece two inches in length. It was 
impoffible to perform this part of the opera- 
tion with a common faw* without cutting 
through the peronaei mufcles. The ufe of a 
trephine would have left four fharp projecting 
points of bone, which would have required the 
affiftance of the ftron^ bone niopers. But the 
faws above defcribed took off the bone with- 
out injury to zyij of the contiguous foft parts, 

D and 



34 On a Wound, &c. * 

and without leaving any projecting point of 
bone. 

The removal of the bone gave us a complete 
view of the wounded artery, in which a hole 
had been made by the point of the pickax, at 
the diftance of three inches above the joint of 
the ancle. The veffel was tied both above and 
below the oriiice, and after the divided inte- 
guments were in part united by futures, the 
leg was placed in a fracture box. 

The patient recovered without any bad 
iymptom. 



[ 35 ] 



CHAP. II 



On the Cataract. 

MY original defign in the following obfer- 
rations was to lay before the reader fuch re- 
marks on the pra6iice of couching, as my own 
experience had enabled me to make ; without 
entering upon a difcuffion of the comparative 
merits of that operation* and the more fafhion- 
able one of extraction* But as Baron Wenzel 
has given, what I efteem to be, a very erro- 
neous account of the difadvantages of the for- 
mer operation ; and as Mr. Ware, the tranfla- 
tor of the Baron's work, appears to coincide 
with this author in his opinion on the fubject ; 
I have judged it neceffary to make fome 
remarks on the Baron's objections* and to 
compare the real difadvantages of the two 
methods of operating for the cure of the 
Cataract* 

I had flniihed my obfervations before Sir 
James Earle's Account of a New Mode of Ope* 
ration fell into my hands ; and as I have had 
no opportunity of feeing Sir James's operations 

D % or 



36 On the Catabtact. 

or even his inftrument, I (hall make no reflec- 
tions on his work, but iincerely wiih, that his 
new mode may be found fuperior in utility to 
any that has been hitherto practifed. 

The term CataraB, when applied to the 
eye, is ufually defined to be, cm opacity of the 
cryftalline humour, or its capfule. This defi- 
nition givesajuft idea of the nature of the dif- 
eafe, but leads to an incorreclnefs in language, 
when fpeaking on the fubject. Opacity, being 
only a quality of the cryftalline, cannot be 
deprefled or extracted. It is the cryftalline 
itfelf, or its capfule that is the fubject of ope- 
ration. We ought, therefore, to fay, that the 
term cataract either exp re fifes an opacity of 
the. cryftalline, or the cryftalline itfelf in an 
qnake ftate. After this definition, we can 
fgeak with propriety of breaking, depreffing,. 
or -extracting: a cataract. 

My own experience having led me to pre- 
fer the mode of depreffion, I fliall lay before 
my reader fuch obfervations on that method 
of operating, as a practice of thirty-three 
years* has enabled me to make; and {hall 

* I entered upon the profeffion of Surgery in the year 
1759, but did not begin to 'perform this operation till 
the year 1768. Since that time, the cafes of Cataract 
which have come under my care have been fo me what 
numerous. . . * ' 

fubjoin 






■ 



On the Cataract. 3 7 

juibjoiri a few cafes to' illuftrate thefe obferva- 
tie us. Thefe, I hope, will not be altogether 
ufelefs to thofe practitioners who may choofe 
to operate. alter this method, which appears to 
me to be both more eafy, and more lare,.. than 
the common method of extraction. 

Before I enter upon thefe ' obfervations, it 
may not' be amifs to make a few anatomical 
remarks on the ftructure of the eye, as far as 
relates to the operation of couching, Thefe 

- 

are the more necefTary, as forne of the lateft 
and beft writers on the operation have deli- 
vered opinions, or directions, inconfiftent with 
tlie ftructure of the eye. 

A furgeon, who undertakes this operation, 
ought to have a clear idea of the ftruSure and 
iituation of the cryftalline humour, and its 
capfule; of the iris; and alfo of the manner in 
which that part of the eye, called its pojterior 
chamber, is formed. • 

The cryftalline may be confidered as con- 
filling of two plano-convex lenfes, of unequal 
bulk and convexity, joined together by their 
flat " furfaces. The larger and more convex 
part of the cryftalline lies fuiik in a cavity 
formed in the anterior part of the vitreous 
humour'; while the fmaller and lefs convex 
portion projects a little before the anterior 

D 3 furface 



38 On the Cataract. 

furface of that humour. That part of the 
cryftalline, which may be considered as the 
place where thefe two unequal portions unite, 
lies contiguous to the brim of the cavity 
formed in the vitreous humour. From this 
brim goes off the capfale which covers the 
anterior part of the cryftalline. And although 
the pofterior portion of the cryftalline is alfo 
inveloped by a capfule, yet it is this anterior 
covering chiefly, which, in fpeaking of the 
catarafii, is denominated its capfule. 

The cryftalline humour is of firm conlift- 
ence at its centre, but becomes gradually 
fofter towards its circumference, where it 
approaches nearly to the ftate of a fluid. The 
centre of the cryftalline is fituated in its pofte- 
rior portion. 

That part of the iris which lies betw r een the 
ciliary ligament and the cryftalline, is covered 
on its pofterior furface with thick projecting 
folds or plaits, called the ciliary proceffes. Thefe 
proceffes adhere flightly to the anterior part of 
the vitreous humour, by the intervention of a 
black fubftance (immediately to be defcribed) 
in their courfefrom the ciliary ligament to the 
brim of that cavity in which the cryftalline 
lies. At this brim they terminate, where 
they are attached to the circumference, of the 

capfule 



On the Cataract. 39 

capfule of the cryftalline. The remaining part 
of the iris lies loofe before the cryftalline, and 
at a very fmall cliftance from it; a minute 
quantity of the aqueous humour, which flows 
through the pupil, being only interpofed be- 
tween them. 

The pofterior furface of the iris, as well as 
the ciliary proceffes, is covered with a black 
fubftance, which, on account of the (limy ftate 
in which it is found after death, is ufuaily 
called pigmentum nigrum. It might with 
greater propriety (as the late Dr. Hunter 
obferved) be called mtmbrana nigra, fince it 
appears to conftitute a fine membrane in the 
living fubje6l. By this latter name I (hall 
diftinguifh it, when I have occafion to men- 
tion it in the following obfervations. 

The pofterior chamber of the eye is that 
fpace, which lies between the iris and the 
capfule of the cryftalline. As the ciliary pro- 
cefTes adhere on all fides to the circumference 
of the capfule, the tranfverfe diameter of the 
pofterior chamber muft be exa6lly equal to 
that of the cryftalline. The diftance between 
the iris and the cryftalline muft be extremely 
fmall, for as the latter projects a little before 
the vitreous humour, and as the former is 
brought very near to that humour by the 

d 4 attachment 



40 0^2 the Cataract. 

attachment of the ciliary proceffes, the irk 
and cryftalline muft be nearly, in contact with 
each other. Indeed, they feem to be kept 
afunder merely by that minute quantity of 
the aqueous humour which flows through the 
pupil, and which ferves to tranfmit to the ex- 
tenor part of the cryftalline the nioft oblique 
rays of light which can enter the pupil. 

The cryftalline humour is iituated, not 
within, but behind, the pofterior chamber of 
the eye. If it is moved dire6ily upwards or 
downwards, its place in the vitreous humour 
will be changed ; but it will not be brought 
into the pofterior chamber. If it is moved 
directly forwards, it may be made- to.pafs 
through the pofterior chamber,, and in this 
tranfit the different parts of it, in fucceffion*. 
will occupy the pofterior chamber; but the 
whole of the cryftalline can never lie in the 
pofterior chamber. When the cryftalline is. 
moved horizontally forwards,, by a needle 
introduced into the vitreous humour behind 
it, the iris does not advance fufficiently to 
permit the cryftalline to remain between it 
and the anterior part of the vitreous humour ;' 
but the pupil becomes dilated, and the cryf- 
talline, as it advances, paffes into the anterior 
chamber of the eye. 

ten 



On the Cataract. 41 

When authors fpeak of depreffing the crys- 
talline in the pofterior chamber of the eye, 
they forget that the tranlverfe diameter of 
the cryftalline, and that of the pofterior cham- 
ber, are the fame ; confequenth r , that it is 
impoffible to deprefs the cryftalline in the pof- 
terior chamber*. 

When they fpeak of introducing a broad 
couching needle into the pofterior chamber of 
the eye, they feem to forget that the iris and 
cryftalline are nearly m contact with each 
other. If the cutting edges of the fpear- 
fliaped needle are placed horizontally in the 
pofterior chamber, for the purpofe of depref- 
fing the cataraft, the anterior edge muft 
wound the iris, unlefs it be placed clirecllv 
oppoiite the pupil, where the iris is deficient. 

* If all that part of the eye which lies behind the iris 
be called the pofterior chamber, the cataract" may then be 
faid to be depreiled in that chamber; but this is not the 
proper anatomical meaning of the term, which fignifies, 
as W inflow has obfervedj a fubdivihon of that part 
of the eye occupied by the aqueous humour. 

" On donne le nom de chambres de 1'humeur aqueufe 
a ces deux efpaces,, & on les diitingue par rapport a la 
fituation, en chambre anterieure & en chambre pofte- 

rieure.- La pofterieure^ qui eft cachee entre V uvee & 

le cryflalhn, eft foit etroite," &g. 

The 



42 On the Cataract. 

The point of a needle, which has penetrated 
the coats of the eye behind, the ciliary liga- 
ment, cannot be brought into the pofterior 
chamber without pafflng through the cryftal- 
line. But it will become vifible to the ope- 
rator, even in a catara£tous eye, before it has 
entirely paffed through the cryftalline : for 
that being generally rendered opake only in 
its central part, the needle becomes vifible as 
foon as it has paffed this part, if the capfule 
"remains tranfparent. 

When the cryftalline humour becomes 
opake, the central part feems always to be the 
firft affe6ted. From the centre the opacity 
extends in all directions towards the circum- 
ference, but rarely, if ever, reaches the cir- 
cumference. For if that were the cafe, un- 
lefs the capfule contained a tranfparent fluid 
furrounding the cryftalline, a mere opacity 
of this humour would be fometimes attended 
with total blindnefs, which, I believe, never 
happens without fome other morbid affection 
of the eye. The ciliary proceffes advance on 
all fides as far as the circumference of the 
cryftalline ; therefore no rays of light can fall 
upon the retina without pafling through the 
cryftalline. 

I can- 



On the Cataract. 43 

I cannot take upon me to fay, whether 
there is, or not, in the human eye during 
life, a minute portion of tranfparent fluid, fur-» 
rounding the cryftalline, and contained with- 
in its capfule, through which the moft oblique 
rays of light may pafs ; but this confideration 
may be neglected, and we may fpeak of the 
cryftalline as filling the capfule, without in- 
curring any practical error. 

In the operation of couching, the cryftal- 
line can only be moved into fome part of the 
vitreous humour, different from that in w T hich 
it is naturally lituated, unlefs it is brought 
into the anterior chamber. It cannot be 
lodged beneath the vitreous humour, as a va- 
luable modern author fpeaks; for that hu- 
mour is every where in contact with the re- 
tina, and fills up the cavity formed by the 
coats of the eye. 

As the needle, which I now ufe in the 
operation of couching, differs fomewhat from 
any that I have feen, and appears to me 
to poffefs fome advantages over the fpear- 
ihaped needle, which is moft commonly 
ufed ; I have given a figure of it, both in 
its natural fize, and alfo when magnified 

for 



44 On the Cataract. 

for the purpofe of feeing its parts more di- 

ftin6tly*. 

The length of the needle is fomewhat lefs 
than an inch. It would be fufficiently long if 
it did not exceed feven-eighths of an inch. It 
is round, except near, the point, where it is 
made flat by grinding two oppoiite fides. The 
flat part is ground gradually thinner to the 
extremity of the needle, which is femicircular, 
and ought to be made as (harp- as a lancet. 
The flat part extends in length about an eighth 
of an inch, and its fides are parallel. From 
the place where the needle ceafes to be flat, 
its diameter gradually increafes towards the 
handle. The flat part is one-fortieth of an 
inch in diameter. The part which is neareft 
the handle is one-twentieth of" an inch. The x 
handle, which ' is three inches and' a half" in 
length, is made of light wood ftained black. 
It is octagonal, and has a little ivory inlaid in 

# In 1768 ^ I had an opportunity of feeing feveral 
operations performed by Dr. Hilmer, an itinerant ocu- 
31ft. He made ufe of a fin all round needle/which ap- 
peared to me fuperioriii point of fafety to. the common 
one, which is larger, and made with, a ipear-ihaped 
extremity. I immediately adopted the form of his 
instrument, making fuch. alterations in it afterwards, as 
I judged likely to increafe its utility. 



3x> fare Jh<;e 44. 



PL. 3 




On the Cataract. 45 

■> 

the two fides which correfpond with the edges 
of the needle. 

The advantages which this inftrument ap- 
pears to me to pofiefs, above the common fpear- 
fhaped needle, are thefe : 

1. It is only half the length of the common 
needle, and this gives the operator a greater 
command over the motions of its point, in re- 
moving the cryftalline from its bed, and tear- 
ing its capfule. It is alfo of fome confequence, 
that the operator mould know how far the 
point of his needle has penetrated the globe of 
the eye, before he has an opportunity of feeing 
it through the pupil ; as it ought to be brought 
forwards when it has reached the axis of the 
pupil. Now he mav undoubtedly form a 
better judgment refpe6ling this circumftance, 
when the length of his needle does not much 
exceed the diameter of the eye, than when he 
ufes one of the ordinary length, which is nearly 
two inches. The fhortnefs of the needle is 
peculiarly ufeful, when the capfule is fo opake 
that the point cannot be feen through the 
pupil. 

2. As this needle becomes gradually thicker 
towards the handle, it will remain fixed in that 
part of the fclerotis to which the operator has 
puihed it, while he employs its point in ds~ 

diTiag 



46 On the Cataract. 

preffing and removing the catara&. But the 
fpear-fhaped needle, by making a wound 
larger in diameter than that part of the in- 
ftrument which remains in the fclerotis, be- 
comes unfteady, and is with difficulty pre- 
vented from Aiding forwards againft the cili- 
ary proceffes, while the operator is giving it 
thofe motions which are neceffary for depref- 
iing the cataracl. 

On the fame account the common fpear- 
fhaped needle may fuffer fome of the vitreous 
humour to efcape during the operation, where- 
by the iris and ciliary proceffes would be 
fomewhat difplaced, and rendered flaccid ; 
whereas the needle which 1 ufe, making but a 
fmall aperture in the fclerotis, and filling up 
that aperture completely during the opera- 
tion, no portion of the vitreous humour can 
flow out fo as to render the iris and ciliary 
proceffes flaccid. 

3. This needle has no projecting edges : but 
the fpear-fhaped needle, having two {harp 
edges, which grow gradually broader to a cer- 
tain diftance from its point, will be liable to 
wound the iris, if it be introduced too near 
the ciliary ligament with its edges in a hori- 
zontal pofition. I have been informed, that, 
in an operation performed by one of the moft 
t) eminent 



On the Cataract. 47 

eminent furgeons in the metropolis, now de- 
ceafed, the iris was divided as far as the pupil. 
If the operator, in order to avoid this danger, 
introduces his needle with its edges in a verti^ 
cal pofition, he will divide the fibres of the 
fclerotis tranfverfly, and by thus enlarging the 
wound will increafe the unfteadinefs of the in- 
ftrument. Befides, however the needle be 
introduced, one of its (harp edges muft be 
turned towards the iris in the act of depreffing 
the cataract; and, in the various motions 
which are often neceffary in this operation, 
the ciliary proceffes are certainly expofed to 
more danger, than when a needle is ufed 
which has no projecting edge. 

4. It has no projecting point. In the ufe 
of the fpear-fhaped needle, the operator's in- 
tention is to bring its broadeft part over the 
centre of the cryftalline. In attempting to 
do this, there is great danger of carrying the 
point beyond the circumference of the cry- 
ftalline, and catching hold of the ciliary pro- 
ceffes, or their inverting membrane, the mem- 
brana nigra. This accident is the more pro- 
bable, as the point of the needle muft un- 
avoidably be directed obliquely forwards, and 
this motion, if carried too far, brings the point 

into 



48 On the Cataract, 

Into contact with the ciliary proceffes, as they 
furround the capfule of the cryftaliine. 

A needle, made according- to the figure given 
in the annexed plate, will pafs through the 
fclerotis with eafe. It will deprefs a firm ca- 
taract readily, and break down the texture of 
one that is foft. If the operator finds it of 
ufe to. bring the point of the needle into the 
anterior chamber of the eye (which is often 
the cafe) he may do this with the greateft 
fafety, for the edges of the needle will not 
wound the iris. In fhort, if the operator, in 
the ufe of this needle, does but attend pro^ 
perly to the motions of its point, he will do 
no unavoidable injury to the eye; and this 
caution becomes the lefs embarraffing, as the 
point does not project beyond that part of 
the needle by which the depreffion is made ? 
the extreme part of the needle being ufed for 
this pur pole. 

The appearance of a cataract has been fa 
often defcribed, that I mail not trouble my 
readers with a repetition of the defcriptiom 
A careful fbrgeon, who understands the ana- 
tomy of the eye, will not often miftake this ; 
difeafe. There is, however, one ftate of the 
eye, which may lead an experienced pra£ti- 
7 tioner 



On the Cataract. 49 

tioner into doubt, or may even caufe him, 
without the greateft circumfpe&ion, to form a 
wrong judgment. In fome perfons, that part 
of the eye which is feen through the pupil 
does not appear black as ufual, but has a grey- 
appearance, or is of a dark pearl colour. This 
is fo like the appearance of an incipient cata- 
raft, that, if the fight of the perfon is dirrii- 
nifhed, a furgeon may be induced to form a 
wrong prognostic. The appearance which I 
have defcribed occurs in one fpecies of amau- 
rofis, to which perfons advanced in age are 
particularly fubjeft. It occurs alfo in fome 
middle aged perfons whofe fight is defeftive. 
In examining attentively the eyes of fuch per- 
fons, one may obferve, that the part which 
puts on a greyifh caft is fituated at a greater 
diftance behind the pupil than an incipient 
cataract, and that it has a more polifhed or 
mining appearance. 

We have no certain criteria by which it can 
be known, previoufly to an operation, whether 
a cataract is foft or hard*. Thofe propofed 
for confideration by Mr. Pott -j- are not to be 
relied upon, Some of the moft firm catarafts ? 

* I have general^ found a dark coloured cataract in 
old perfons to be of a firm confidence, 
t Pott's Chirurgical Works, vol. iii, p. 222. 

E which 



5o On the Cataract, 

which have occurred in my practice, were nei- 
ther formed haftily, nor preceded by pain in 
the head. On the other hand, two cataracts* 
which came on the moft rapidly of any that I 
javjhfeen, and which feemed to have been 
>^ fi^me^'-ialmoft inftantaneoufly, were found to 
tjSj iopCy \ The fubject, in one of thefe cafes* 
y$$& a^majrried woman, who had enjoyed per- 
^ f§£t iijgfitf until the time of her fifth labour* 
^ Simelimtely after her delivery me became 
|m%3^ of a confiderable defect in her fights 
and could afterwards difcern no object dis- 
tinctly. Soon after me had got abroad, her 
hufband brought her to Leeds, and confulted 
me. I found a cataract formed in each eye, 
and, upon operating a fhort time afterwards* 
the cataracts were found to be uniformly 
foft. 

When a cataract is complicated with a 
complete amaurofis, or a total opacity of the 
cornea, the removal of the difeafed cryftalline 
muft be fruitlefs. But in partial affections of 
the eyes from thefe complaints, a patient may 
receive fuch a degree of fight from an opera- 
tion as yields much comfort, though it falls 
fhort of diftinct vifion. An univerfal adhefion 
of the iris to the capfula of the cryftalline 

argues 



On the Cataract* 51 

argues fucha morbid ftate of the eye, that an 
operation cannot be undertaken witho ut con- 
fiderable doubt refpefting the event, though 
the operation is not hereby rendered wholly 
improper. In this cafe, the iris fhews no 
motion upon a fudden expofure to light, the 
pupil ufually remains contracted, and is often 
irregular in its form. I have repeatedly ope- 
rated with fuccefs where the adhelion was par- 
tial, by proceeding with great caution. In 
this cafe, the pupil is contracted and dilated, 
by varying the degree of light thrown upon 
the eye. Sometimes when the pupil is cir-? 
cular in a ftrong light, it will, when dilated 
in an obfcure light* affume an irregular form, 
and thereby point out the fituation and ex- 
tent of the adhenon. 

Though it would be improper to perform 
the operation of couching, when the eye is in 
a ftate of inflammation ; yet perfons affe6ted 
with the Lippitudo bear the operation much 
better than one would expefl from the ap- 
pearance of the eyes in that difeafe. I have 
never reje6led a patient on this account, but 
have repeatedly performed it with fuccefs, and 
with very little fubfequent inflammation, when 
numerous veflels of the conjunctiva were tur- 

£ 2 gid 



52 On the Cataract. 

gid with blood, and the eye-lids thickened, 
provided this ftate of the organ was habitual. 

I do not recommend an "operation, if the 
difeafe is confined to one eye, while the fight 
of the other eye remains perfect. Nor am I 
hafty in recommending the operation in cafes 
of catara6l from external injury, as blows, or 
punctures of the cornea; having been led 
from experience to form the fame opinion of 
the difeafe, when originating under fuch cir- 
cumftances, which the late Mr. Pott enter- 
tained^. I apprehend that, in fuch cafes, 
the capfule of the cryftalline is generally the 
feat of the difeafe ; and I have had the plea- 
fure of feeing the opacity difappear gradually, 
without the-ufe of any other means than thofe 
which were proper for removing the inflamma- 
tion. Such an event, however, does- not al- 
ways follow ; and fometimes where' the light 
is ultimately reftored without an operation > 
the reftoration advances by very flow degrees. 
My late colleague at the General Infirmary, 
Mr. Lucas, relates a cafe*f in which " the 
" opacity began to diffipate in a month" after 
the accident, which was a blow upon the eye, 

* Pott's Chimrgical Works, vol. iii. p. 230. 
t Med. Obf. and Inquiries, vol. vi. p. 264. 



On the Cataract. 53 

" and in three months the patient could fee 
" with that near as well as the other eye." I 
have feen two cafes, where the opacity con- 
tinued a year before the natural transparency 
of the capfule began to be reftored. In the 
laft cafe of this kind which I faw, the patient 
had been blind of the injured eye four years 
before the opacity began to difappear. 

When the cataract is congenital, the eyes 
have often an irregular motion, as if the pa- 
tient was looking at two diftinct obje£ts at the 
fame time. The operation is rather more 
difficult in fuch patients, on account of the 
unfteadinefs of their eyes ; but it may be per- 
formed with fafety, when the patient is fo far 
advanced in years as to underftand the de- 
fign of the operation, and has been taught to 
defire it. I once attempted to couch the eyes 
of a child two years old, the fuccefs of which 
operation will be related* ; but I have always, 
except in this inftance, refufed to operate on 
fo young a fubjecl. 

The habit of perfons afflicted with cataracts 
is fo different, that no general rule can be 
laid down refpecting the manner of preparing 
a patient for the operation. In fome cafes, 
thelofsofa little blood may with propriety 

* See Cafe 8. 

E 3 be 



B4> On the CatahaciV 

be added to laxatives, and a ftrict regimen. 
In other cafes, there mav be fuch conftitu- 
tional debility as to forbid any reduction. In 
general, I do but require my patients to ab- 
ftain from animal food and fermented liquors 
for a few days, and give one dofe of a gentle 
purgative. 

During the operation, the patient mould be 
feated in a chair fomewhat lower than that on 
, which the operator fits, that the arm of the 
operator may not be much elevated. An 
elevated pofition of the arm foon produces 
fatigue, and renders the hand lefs fteady. 
The eye of the patient mould be expofed to 
the light of one window only, and that fhould 
admit no more light than is neceffary for 
feeing the interior parts of the eye diftinctly. 
If the patient's head is placed a little oblique- 
ly to the light, the piclure of the objects re* 
fleeted by the cornea (which often prevents a 
diftinct view of the cataract) is thrown to one 
fide of the pupil, and then creates no impedi- 
ment to the operation. A horizontal light is 
in this operation preferable to a fky-light. The 
head of the patient muft be kept erect, or in- 
clined a little forwards, by an affiftant who 
places one hand upon the forehead, and ano- 
ther 



On the Cataract. 55 

ther under the chin, fupporting at the fame 
time the occiput by a pillow interpofed be- 
tween it and the breaft of the affiftant. The 
eye, which is not the immediate fubject of the 
operation, mould be kept fteady by a proper 
bandage, and by a gentle preffure from that 
hand of the affiftant which is placed upon the 
forehead. If a fpeculum oculi is not ufed, the 
operator may fupport the upper eye-lid with 
the thumb of one hand, and with the ring 
finger of the other hand, which holds the 
needle, deprefs the lower eye-lid till he has 
introduced the needle. After that, it is more 
convenient to have the lower eye-lid held 
down by an affiftant. The tarfus fhould be 
turned ^ little inwards, and the eye-lids gent- 
ly preffed againft the edge of the orbit, and 
the globe of the eye. I have found the com- 
mon fpeculum oculi to be inconvenient, and I 
have never tried that which is recommended 
by Mr. Benjamin Bell*. The patient fhould 
be directed to turn his eye inwards, as if lie 
were looking at his nofe, that the part in 
which the punfture is to be made may pre- 
fent itfelf to the operator, and that the con- 
junctiva may be put upon the ftretch. If the 
conjunctiva remains wrinkled where the needle 
enters the eye, the operator will find his iil- 

* Bell's Syftem of Surgery, vol. iii. p. 244, plate XXX. 

Tj 4 itrument 



56 On tfie C at a k act. 

ftrument fo entangled as greatly to impede 
the regularity of bis motions. 

The needle, being befrheared with oil, 
fhould be pufhed fuddenly through the coats 
of the eye. The direction in which this is 
done is of fome confequence, efpecially if a 
fpear-fhaped couching needle is ufed. The 
needle Ihould not be pufhed through the 
fclerotis in a dire6lion parallel to the iris ; for 
preffure made in that dire6tion is apt to give a 
rolling motion to the eye, and thereby alter 
the courfe of the needle. If the eye be made 
to roll towards the nofe, the point of the needle 
will then be dire6ted towards the iris, and the 
operator will be in danger of wounding it. 
This danger may be avoided by piercing the 
fclerotis with the point of the needle directed 
towards the centre of the eye. By this me~ 
thod the eye is rendered fteady, and the 
needle will .pafs through its coats without any 
danger of wounding either the iris or ciliary 
proceffes. 

When the needle has pierced the coats of 
the eye, it rauft be pufhed forwards in the 
fame direction, till fo much of the inftrument 
is introduced, that its point, when brought 
forwards, will reach the centre of the cryftal* 
line. This part of the operation, as I have 
6 already 



On the Cataract. 57 

already obferved, may be performed with 
greater exactnefs by the ufe of a fcort needle. 
If the length of the needle is little more than 
the diameter of the eye, the operator will be 
greatly affifted in judging when the point of 
his inftrument has advanced to the .axis of the 
pupil, which correfponds with the centre of the 
cataract. It is not abfolutely neceffary, that 
the needle fhould be introduced at one determi- 
nate diftance behind the ciliary ligament. 
Indeed, the want of fteadinefs in the eyes of 
fome patients renders this impracticable : But 
I coniider the diftance of about one-flxteenth 
of an inch to be the moft convenient. The 
operation may be performed with greater eafe 
and fafety, when the needle pierces the fcle- 
rotis near the ciliary ligament. 

So far the operation muft be conducted in 
the fame manner, whatever be the ftate of the 
cataract. The remaining part of the opera- 
tion muft be varied according to the circum- 
ftances of the difeafe. 

If, in bringing forwards the point of the 
needle, I perceive the cataract to advance, and 
dilate the pupil ; I then know that the cataract 
is firm, and that the needle is in contact with 
its pofterior part. The preffure ufed in bring- 
ing forwards the cataraft, fometimes caufes 

the 



58 On the Cataract. 

the point of the needle to fink fo far into the 
cry ftalline, and to become fo much entangled 
in its more tenacious part, that the depreffion 
may be completed though the inftrument has 
not been feen through the pupil. When, 
therefore, the appearance which I have men- 
tioned takes place, I do not perfift in bringing 
* forwards the point of the needle, left the iris 
fhoujd be injured by the too great dilatation of 
the pupil ; but I deprefs the point, and at the 
fame time carry it backwards. If this motion 
of the needle removes the cataract from its 
place, the operation is ufually concluded with- 
out any farther trouble. 

If the cataract does not follow the motion 
of the needle, I cautioufly bring forward its 
point through the fofter part of the cryftalline, 
till I can fee my inftrument through the pupil, 
and then proceed in my attempts to effe6t the 
depreffion. In thefe attempts I always move 
the needle backwards as well as downwards ; 
for the operator ought always to be fure, that 
his needle is behind the ciliary proceffes when 
he moves it upwards or downwards. Before 
I withdraw the needle, I ufually elevate its 
point a little, to fee whether the catara6l rifes 
again when the preffure is removed. If it 
does, the preffure is renewed once or twice, 

and 



On the Catahact. 59 

and the needle is then withdrawn. I always 
endeavour to lodge the catara£t below the 
place where my needle entered the vitreous 
humour, and withdraw the needle in a direc- 
tion nearly parallel with the axis of the pupil. 

Though I do not think it advifable to per- 
fift in preffing an entire cataract into the ante- 
rior chamber, when the advance of the cata- 
ract caufes a large dilatation of the pupil ; yet 
after the needle has, wounded the capfule, a 
firm cataract, or at leaft its nucleus, will fome- 
times flip through the pupil without the defign 
of the operator, This has been confidered by 
fome authors, as a difagreeable circumftance, 
and has been ranked amongft the objections 
to the operation of couching*. On the con- 
trary, it ought to be confidered as a favour- 
able event, iince the cataract always diffolves 
in the aqueous humour, and finally difappears 
without any injury to the eye. This, at leaft, 
has been the event in every cafe of the kind 
which I have feen. I have fix or feven times 
feen the whole opake nucleus fall into the ante- 
rior chamber of the eye, and very frequently 
fmall opake portions. Indeed, if the cataract 
could, in all cafes, be brought into the anterior 

f Memoires de i'Academie de Chirurgie.. torn. ii. 579. 
Warner's Cafes, ed. 3. p» 76 — 92. Bar. Wenzel. 

chamber 



60 On the Cataract. 

chamber of the eye, without injury to the iris, 
it would be the bed method, of performing the 
operation. But this is not ufually practicable ; 
the foftnefs, as well as the bulk of the cataract 
prefenting an obftacle to this procefs. 

If the cryftalline, or rather its capfule, is 
found to adhere in part to the iris, great cau- 
tion mould be ufed in our attempts to de- 
ftroy the adhelion ; as it is much more fafe 
to repeat the operation after a gentle attempt, 
than by continuing the ufe of force to rifque 
the danger of an inflammation. It is ufeful 
in this cafe to lift up the cataraft with the 
needle, as elevation may be fuccefsful, where 
depreffion has failed. Mr. Warner fucceeded 
at the fourth operation, in deftroying an 
adhelion of .the iris ^ ; and I have repeated 
the operation oftener than four times with ad- 
vantage, rather than incur the hazard of 
inflammation, which might have left my pa- 
tient in total blindnefs. 

Hitherto tbe cataract has been confidered 
as firm, and capable of bearing the preffure of 
the needle ; but in the greater number of 
cafes, which have fallen under my care, the 
cataracls have been found fo foft as to permit 
* Warner's Cafes in Surgery, ed. 3. p. 62. 

the 



On the Cataract. 61 

the needle to pafs through them in all direc- 
tions. In this ftate of the difeafe I do no- 
thing more than break down the texture of 
the catara6fc, and endeavour to punfiture, or 
tear off, a portion of the capiule, that the 
aqueous humour may flow in upon the broken 
catara£L In doing this, it is common to fee 
fome fragments of the catara6t fall, through 
the pupil, into the anterior chamber of the 
eye. I am always glad to fee this take 
place, as I then know that there is a paflage 
opened for the admiffion of the aqueous hu- 
mour, and that thofe opake fragments, which 
have panned through the pupil, will foon dis- 
appear. 

Sometimes the cataraft is fo uniformly foft, 
that the paflage of the needle through it 
makes no alteration in its appearance. This 
fpecies of cataract was confidered by the late 
Mr. Sharp and Mr. Warner as incurable*. 
In this opinion thefe excellent authors were 
certainly under a miftake ; for I find that 
although an uniform foftnefs of the cataraft 
may require a more frequent repetition of the 
operation, it affords no permanent impediment 

* Sharp's Operations of Surgery, ed. 7th. 163*—165. 
Warner's Cafes in Surgery, ed. 3d. p. 73. 

to 



On the Cataract* 
to the cure. Upon repeating the operation 
in fuch cafes I have often found, that the firflj 
©peration had produced more effect than at 
the time of operating it appeared to produce. 
The cataract, upon a fuhfequent operation* 
appears more broken, and irregularly opalie. 
Some portions may now be removed, which 
before appeared immovable ; fome fall into 
the anterior chamber ; and the remainder 
becomes gradually diffolved in its original 
fituation. 

When both eyes are affected with a cataract, 
I ufually operate upon them both at the fame 
time; nor have I feen any reafon for difcon- 
tinning this practice. 

I always operate upon the right eye with 
my left hand. A furgeon may eafily acquire 
the power of ufing his left hand in this opera- 
tion, if he accuftoms himfelf to bleed with the 
left hand, whenever a proper opportunity 
offers. 

After the operation, I cover both the eyes, 
though one only may have been couched, with 
a broad piece of linen, fp read with unguentum 
cene, and faftened to a ribbon tied round the 
head. The patient's face mould not be expofed 
to a ftrong light, nor to the heat of a fire, till 
the tendernefs of the eyes is gone off. A ftrict 

regimen 



On the Cataract. 63 

regimen fhould be obferved for a few days ; 
and a gentle laxative may ufually be given 
with advantage. 



When the nature and variety of the parts 
wounded in couching are confidered, a perfon 
not accuftomed to this operation might reafon- 
ably conclude, that it would ufually be followed 
by a considerable degree of inflammation. 
Yet I can with truth affert, that when it is 
performed in the manner above defcribed, the 
ufual confequence is nothing more than a ten- 
dernefs of the eye, which goes off by degrees, 
if the patient ufes the proper cautions. Fre- 
quently the eye appears as free from inflam- 
mation as it did before the operation, except- 
ing a flight rednefs in the conjunctiva, where 
the puncture was made. Nor is the operation 
itfelf attended with that degree of pain which 
one might reafonably expect. It is commonly 
fpoken of by the patient as inconiiderable. 
A lady, whom I couched in this town, was 
afked by her daughter immediately after the 
operation, what degree of pain lhe had felt. 
Her reply was this : " I expected to have felt 
" an acute pain, though of Ihort duration; 
" but I did not. I only felt as if fomething was 

** preffing againft mv eve." 

Though 



64 On the Cataract. 

Though the inflammatory affection, which 
is immediately fubfequent to the operation, is 
generally flight, yet it muft be confeffed, that 
it is fometimes confiderable ; and I have alio 
obferved, that the patient's eye is more fufcep- 
tible of inflammation, from any irregularity, for 
two or three weeks after the operation. Some 
of the worft attacks of inflammation, which I 
have feen, have come on at fo diftant a period; 
when the patient, prefuming upon the com- 
fortable flate in which he found himfelf, has 
incautioufly expofed his eye to a cold blaft of 
air, or has caught cold by any other means. 

In cafe of fubfequent inflammation, I place 
the greateft dependance upon the evacuation 
of blood from fome branch of the temporal 
artery. The quantity and frequency of the 
evacuation muft be directed by the circum- 
ftances of the cafe ; but it ought to be ufed 
freely till the inflammation begins to fubfide. 
Purgatives, and other cooling remedies mould 
be added. Warm foft water, directed in a 
gentle ftream acrofs the eye, abates the pain 
in the acute ftage of the inflammation. When 
that has fome what fublided, the face, the neck, 
and head, if not covered with hair, fliould be 
frequently warned with cold water. 

Sometimes. 



On the Cataract. 65 

Sometimes, when the eye is not inflamed, 
the patient feels pain in the forehead, juft 
above the eye-brow, which is now and then 
accompanied with ficknefs or retching. This 
complaint is the moil effectually relieved by 
an opiate. 

I have feen.a few inftances where the eye, 
upon being examined fome days after the ope- 
ration, has appeared to be affected with an 
amaurofis. The pupil has been found largely 
dilated, and the patient has had a weak per-* 
ception of light. I know not how to account 
fatisfactorily for this accident, which i as far as 
I have feen, is more alarming than dangerous. 
In the few cafes of this kind which have 
fallen under my notice, bleeding has appeared 
to relieve the complaint ; the iris has by de- 
grees regained its contractile power, and the 
retina has been reftored to its natural fenfibi- 
lity. One patient, indeed, who came to the 
General Infirmary from Bridlington, to whom 
this circumftance occurred, refufed to ftay in 
the houfe till the complaint had ceafed, and 
returning home in cold weather* before the in- 
flammatory tendency had fubfided, had after- 
wards, as I was informed, a fevere attack of 
inflammation. His prefent ftate I do not 
know. Another, whofe cafe I fhall relate, 

F wa,s 



€8 On the Cataract. 

was attacked with a temporary amaurofis, after 
fhe had regained her fight, and had left the 
Infirmary*. 

It would fcarcely be necelTary to mention 
the rifing again of the cataract,- when enume- 
rating the confeauences of the operation, but 
that fome good authors have confidered this 
as a circumftance, which affords an important 
objection to the operation of couching, and 
renders it fruitlefs. This cireiimflaiice may 
require a repetition of the operation, but 
throws no hindrance in the way of the cure. 

* Since thefe obfervations were written, a cafe has 
occurred, in which the pupil became largely dilated 
after the operation, and did not regain its natural form. 
I couched both the eyes of an elderly man in the Gene- 
ral infirmary ; and while I was operating upon the right 
e\ r e, the cataract broke in pieces, and fell into the ante- 
rior chamber, at the moment in which I was depreffing 
it with niy needle. I imagine that I did not direct my 
needle furEciently backwards in the act of depreffing^ 
but incatrtiouily touched the lower part of the ins r in 
confequenceof the obfcurity which at that inftant took 
place, and hid my inftrument from view. A consider- 
able degree of inflammation fupervened in that eye, and 
the pupil remains too much dilated, and vertically ob- 
long. The patient fees very we'll with the left eye ; and 
even with the right can read a moderate fized print, 
whenaffifted with two pairs of fpectacles. 

This is the only accident of the kind (as far as I re- 
collect), which has occurred to me during the whole 
courfe of my practice. 

if 



On the Cataract. 67 

If the cataracl:, though rifen again into view, 
appears detached, fo as to move fenfibly and 
readily in the vitreous humour, with every 
motion of the head, it will generally, by de- 
grees, fubfide and finally difappear without 
any farther affiftance. 

In two cafes I was led to fufpect, that the 
removal of the cataract had detached a fmall 
portion of the membrana nigra from the cili- 
ary procefles. In both thefe inftances, the 
patient could fee diftinctly immediately after 
the operation ; but in the courfe of a week 
the light became obfcure, though there was 
no fubfequent inflammation, no opacity in- the 
cornea, nor morbid dilatation of the pupil. 
The cataracts were firm, and were eafily de- 
preffed; nor did they appear to have rifen 
again. One of thefe patients complained that 
objects appeared blue to her ; but her fight 
remained fufliciently good to enable her to 
do the ordinary bufinefs of her houfe. The 
other patient came from Cumberland, and I 
have had no opportunity of knowing what de- 
gree of fight he continued to enjoy. 

A frequent and moft important confequence 
of the operation, and one that fucceeds the 
method of extraction, as well as that of de- 
preffion, is an opacity of the capfule of the 

r 2 crvftalline 



68 On the Cataract. 

cryftalline. This fecondary cataract will ap- 
pear when no inflammation has fucceeded the 
operation. It will fometimes difappear by the 
effect of time, as in cafes of cataract from 
blows or punctures ; but this event is often 
How, and always uncertain . If time does not 
remove this difeafe, recourfe muft be had to 
the needle- When an aperture has been 
made in the centre of the capfule, at the time 
of the depreffion, and remains fo large as to 
enable the patient to fee diftinctly, the opacity 
of the furrounding part of the capfule need 
not be regarded. But if any opake portions 
occupy the axis of the pupil, and do not foon 
Chew fome return of tranfparency^ it is proper 
to repeat the operation, for the purpofe of 
breaking afunder, or removing, the opake 
portions. 

When portions of the opake capfule hang 
floating in the pofterior chamber of the eye, it 
is difficult to pierce, or lay hold of them. The 
attempt to remove them muft be made in dif- 
ferent directions, yet with great caution, left 
the iris mould be injured. I have fometimes 
fucceeded in detaching thefe portions by mov- 
ing my needle upwards, when the motion 
downwards has failed to lay hold of them. 

3 Wheri 



On the Cataract. 69 

When the capfule appears in crofs threads 
like net-work, the inftrument will readily 
break them afunder. Sometimes the capfule 
has a confiderable degree of elafticity, and 
fprings up again immediately with force 
after being depreffed. When fragments of 
this kind are near the circumference of the 
cryftalline, and do not materially interrupt 
the paflage of the rays of light, it is the moft 
prudent method to leave them, left the ciliary 
proceffes mould be injured by tearing them 
off. 

As the opacity of the capfule, which forms 
the fecondary cataract, is ufually diminimed in 
fome degree by time. I confult the inclination 
of my patients with refpeft to the time and 
frequency of thefe fecondary operations. A 
labouring man, who has a family to maintain 
by his work, will not perhaps regard a fre- 
quent repetition of the operation, that he may 
the fooner return to his labour. Perfons of a 
higher rank often prefer a delay. The lady, 
whofe defcription of the pain arifing from the 
operation I have already mentioned, had a 
fecondary cataract in each eye. She chofe 
to have the operation repeated upon one eye, 
and to wait the effect of time upon the other. 
Both methods fucceeded ; but there was no 

F 3 return 



70 On the Cataract. 

return of tranfparency in the capfule of that 
eye for which the needle was not employed, 
till about fix months after the depreffion of 
the cataract. A gentleman of my acquaint- 
ance, from whom the late Baron Wenzel ex- 
tracted two cataracts, had a fecondary cata- 
ract in both eyes. The opacity continued 
two years after the extraction of the cata- 
racts. After that time I had no oppor- 
tunity of examining his eyes, but was in- 
formed that his fight had improved before his 
death, which happened about two years after 
I laft faw him. I never knew but one in- 
ftance in which the broken fragments of the 
capfule coalefced, and became reunited. This 
cafe I (hall relate. 

I have often feen, in perfons who have been 
couched, and fometimes in thofe who have 
never had a cataract, a tremulous motion of 
fome transparent fubftance in the anterior 
chamber of the eye. May not this be owing 
to fome portion of the vitreous humour which 
has paffed through the pupil ? I never faw 
any degree of opacity in this fubftance, nor 
does it feem to create any impediment to per- 
fect vifion. 

The vitreous humour does not appear to 
fuffer the leaft injury by the paflage of the 
needle or cataract through it. If there was 

any 



On the Cataract. 71 

any tendency in this humour to become 
opake, we fhould frequently fee this confe-; 
quence enfue from the operation of couching. 
JBut no fuch confequence* I believe, was ever 
known to enfue. On the contrary, this hu- 
mour feems to be in as proper a ftate for the 
tranfmiffion of light after the operation, as it 
was before. 

Surgeons, who undertake the operation of 
couching, mould not be induced by their de- 
iire of completing the cure at one operation, 
to ufe long continued efforts to deprefs or 
break down a cataract. By fuch efforts there 
is great danger of injuring the eye. It has 
been too much considered as a matter of dif- 
grace to the operator, if fight has not been 
immediately r eft o red to the patient. The 
fear of this difgrace has probably configned 
many an unhappy fufferer to irremediable 
blindnefs. A cautious procedure, though 
more flow in its progre fs, will more furely ar- 
rive at the defired end. Neither the pain, 
nor the danger attending the operation, is 
great, if it be conducted with caution ; and 
when a patient has been informed of the ope- 
rator's defign, and finds lefs inconvenience 
from the operation than his tears had led him 
to expect, he will feldom object to that treat- 

F 4 ment 



72 On the Cataract. 

merit which affords him the greateft hope of 
regaining the bleffmg of fight. When cuftom 
has reconciled our patients to hear without 
furprize, that a repetition of the operation is 
often neceffary to effect a cure ; , they will no 
more think this circumftance a difparagement 
to the art, than when they hear that repeated 
bleeding is often neceffary to cure an inflam- 
mation. One principal thing to be kept in 
view by the operator is, to do no harm. If 
he fecures this* he will almoft certainly do 
fome good* and often much more good than 
he expefts. An operation may be performed 
without the leaft apparent advantage at the 
time, and yet in the end may prove the means 
of cure. The operation of couching has been 9 
till of late, chiefly confined to itinerant ocu- 
lifts, whofe mode of life requires difpatch. 
They are therefore obliged, let the date of 
the cataract be what it may 9 to continue their 
efforts till it is either removed, or fo far bro^ 
ken down, that fome rays of light may be im- 
mediately admitted. Various objecls are 
then prefented to the patient, and if he can 
difcern them, he is pronounced cured, and 
prompt payment is required, without regard 
to the future confequences which this method 
of treatment may produce. I am convinced 

that 



On the Cataract. 73 

that many perfons, whofe cafes were not in- 
curable, have been rendered totally and irre- 
coverably blind by this mode of procedure, 
when there was no want of dexterity in the 
operator. 

When I confider the opinion of thofe enn- 
nent furgeons, Mr. Samuel Sharp and Mr, 
Warner, refpectin^ the effect of this onera- 

' X. O JL 

tion, I cannot avoid concluding, that the me- 
thod of couching above recommended is pre- 
ferable to that which has been commonly 
practifed. Mr. Sharp's words are, " After 
all, there will fometimes enfue a trouble- 
fome ophthalmy, which, zrith the uncer- 
*' tainty there ahvays is of fuccefs after the 
operation, have deterred molt furgeons from 
undertaking it*." And Mr- Warner fays, 
It is neceiTary to be allured, that the fuccefs 
f ' of this operation, which at beji is preca- 
" rious, is much more fo, when there is an 
" adhelion of any part of the difeafed chry- 
" jialline to the tunica iris-f. 

There is no operation of furgery which may 
not fometimes fail of fuccefs; but couching, 
when conducted in the manner above advifed, 
fo rarely fails to reftore a eonfiderable degree 

* Operations of 'Surgery, ed. 7- p. 165. 
t Cafes of Surgery, ed. 3. p. 57. 

of 






74 On the Cataract. 

of fight, if the cataract is not complicated with 
any other morbid aifection of the eye, that it 
cannot be confidered as attended with much 
uncertainty. 

I fhould have been glad to have drawn a 
fair companion between this operation and 
that of extraction ; but as I have already ob- 
ferved, it is not in my power to do this from 
my own experience. I never performed the 
operation of extraction but once, and then 
took every precaution to enfure fuccefs. 
I chofe a patient who had a cataract 
in each eye, who was free from any appa- 
rent tendency to inflammation in the eyes, 
and whofe cornea was fufficiently pro- 
minent. 1 extracted the cataract from the 
left eye, that I might have the advantage of 
ufing my right hand. No accident occurred 
in the operation ; and great care was taken to 
prevent a fubfequent inflammation : yet the 
inferior half of the cornea became opake, fo as 
to deprive my patient of the benefit of the 
operation. 

The event of this cafe gave me fo much 
concern, that I never attempted the operation 
again. I afterwards couched this patient's 
right eye with my left hand as ufual, and fhe 
regained the complete fight of that eye. 

Recollecting 



On the Cataract. 75 

Recollecting the place where the poor 
woman lived, who was the fubjecfc of thefe 
operations about eighteen years ago, I lately 
made fome inquiry concerning her. I found 
that {he had been dead about nine years. I 
met with her daughter (a middle aged woman), 
and was informed by her, that her mother had 
continued to enjoy the fight of her right eye 
as lono; as me lived, and was able to read her 
Bible, though a fmall print, with great readi- 
nefs ; but that me had never been able to dif- 
tinguifh objects with the left eye, unlefs fuch 
as were placed above her. 

If I may be allowed to judge from the re- 
ports of feveral of my pupils, who, after feeing 
for fome years the practice of the General In- 
firmary at Leeds, have been pupils at other 
hofpitals, where the method of extraction is 
adopted, I mould conclude, that the advantages 
are greatly in favour of the mode of depref- 
fion above defcribed. 

It defer ves to be here remarked, that the 
operation of couching is lefs difficult than that 
of extraction. Of this opinion was the late 
Mr. Sharp * ; and no inconfiderable teftimony 
to the validity of this opinion is afforded by 
the following fact, that all the patients who 

* Critical Inquiry, ed. 4. 264. 

undergo 



76 On the Cataract. 

undergo the operation of extraction, in one 
of the principal hofpitals of the metropolis, 
are committed to the care of one furgeon ; 
though the reft of the furgeons, who decline 
this operation, are in the habit of perform- 
ing all others, which the cafes of their refpec- 
tive patients may require. 

I have fubjoined a few cafes, by way of il- 
lustrating fome of the observations made in the 
preceding pages. 

CASE I. 

CataraSt with Lippitudo. 

June 22d, }775, I couched both the eyes 
of an old man, whofe cafe was attended with 
the following unfavourable circumftances. His 
eye-lids had been fore and turgid for fome 
years. His eyes were watery, and appeared 
to be in an irritable ftate. The left cataract 
was firm, and was removed intire ; but the 
right was rather foft, and fuffered the needle 
to pafs through it. The next day his eye- 
lids were a little more fwelled, and he com- 
plained of a flight pain over the right eye- 
brow. His left eye was not at all inflamed ; 

and 



On the Cataract. 77 

and the conjunctiva of the right had very- 
little more rednefs than before the operation. 

July lft. His right eye was quite eafy, and 
he could fee a little with it. The cataract in 
the left eye appeared again ; but in a few 
weeks it became fenfibly wafted. His fight 
was gradually reftored, fo that at the end of 
September following he could fee very well. 

In the year 1 799, I couched both eyes of 
the Rev. Mr. Pattenfon of Ripponden, which 
were in the fame morbid ftate as that above 
defcribed, and had been fo for many years, 
The operation was twice performed upon each 
eye, with the interval of a few weeks ; but at 
neither time did it caufe much alteration in the 
thickening of the eye -lids, or turgid ftate of 
the veflels of the conjunctiva. Sometime after 
his return home, he wrote to me to inform me 
of his comfortable fituation, which he thus de- 
fcribes : " I thank God, I can do my duty in 
" the ^hurch, and in the fchool, with almoft 
" as much eafe and comfort as at any former 
" period of my life." 

Mr. Pattenfon's eyes were in fo tender a 
ftate before the operation, that be had been in 
the habit of wearing a green {hade upon his 
head. In reference to this he makes the fol- 



lowing 



78 On the Cataract. 

lowing obfervation in his letter : " I have no 
" pain in my eyes, and feel no inconvenience 
€i from walking without any (hade over them, 
* s except in a ftrong fun." 

CASE II. 

Soft CataraS. 

In 1776, William Birkenfhaw of Billing! ey, 
who had loft one eye, came under my care at 
the General Infirmary, on account of a cata- 
ract in the other. I found it uniformly foft 
and yielding, permitting the needle to pafs 
through it in any direction, without changing 
its pofition or appearance. At the requeft of 
my patient, I repeated the operation after a 
fhort interval, but with no greater fuccefs than 
before. Not difcouraged myfelf by this ap- 
parent failure, I explained to the poor man the 
reafon of the hope which I entertained of fuc- 
ceeding finally by a repetition of the opera- 
tion. He gained confidence by my repre- 
fentation, and as he had a large family to 
maintain by his labour, and was, therefore, 
anxious to regain his fight as foon as poffible. 
I yielded to his folicitations, by repeating the 
operation with fhorter intervals than ufual. 
The cataract put on by degrees a broken ap- 
pearance ; 



On the Cataract. 79 

pearance ; and being partly diflblved, or re- 
ftored to tranfparency, and partly removed 
by the needle, a perfect cjtre was at length /&) 
obtained. I couched him feven times, vet he 
never teemed to have the leaft fear of the ope- 
ration. He had rarely any rednefs in the 
conjunctiva in confequence of the operations^ 
except about the puncture, and feemed to fuf- 
fer very little from them. I faw him about 
two years after his cure, when he informed 
me with great pleafure, that he was then able 
to maintain by his labour a family, confifting 
of his wife and feven children. 

CASE III. 

Partial Adhejion of the Iris to the Cataract. 

John Healde, aged twenty-three, was ad- 
mitted into the General Infirmary in June 
1 774, on account of a cataract in his left eye. 
I was apprehensive, from the appearance of 
the part, that the difeafe was feated in the 
capfule of the cryftalline, rather than in the 
humour itfelf ; for a fmall portion in the mid- 
dle of the cataract was tranfparent, while the 
upper and lower parts were opake. The up- 
per opake part appeared thin ; but the lower 

appeared 



SO On the Cataract. 

appeared thick and fhrivelled, and was of a 
pale yellow colour* 

The right eye was enlarged, and diftorted; 
having an opake cryftalline, and an immove-* 
able iris. 

The patient gave me the following account 
of his cafe. He was ftruck upon the left eye 
by a cinder thrown at him when he was {even 
years old. A violent inflammation fueceeded 
the injury, and ended in a total lofs of fight. 
He remained blind of this eye till he was nine- 
teen. About that time the right eye became 
dim, and enlarged; yet in the left he regained 
a fmall degree of light, which had continued? 
fo that he could conduct himfelf in walking, 
though he could not execute his ordinary 
buiinefs. There was a tremulous motion 
obfervable in the anterior chamber of the left 
eye, though the fluid which it contained was 
tranfparent. The iris was a little concave 
anteriorly. 

I performed the operation June 7th, and 
found the two opake portions connected with 
the cryftalline, and the fuperior one adhering 
to the iris. I could not readily break this ad- 
hefion, and therefore left the parts in their 
former ftate, after making fuch attempts to 
detach, the cataract, as I judged confident 

■with 



On the Cataract, 81 

"With the fafety of the eye; He feemed to 
fuffer more pain than ufual from the operation* 
and became lick with it. The pain ceafed in 
about an hour and a half, and never returned, 
except that he iiad how and then a flight 
pricking fenfation in the eye* 

June 24th, I couched him a fecond time, 
but could not feparate the upper part of the 
cataract from the iris. No inflammation foe- 
ceeded the operation. 

July 4th, He was couched the third time* 
The cataract ftill adhered to the iris, but no* 
Co firmly as before* No inflammation iuper*£ 
vened. * 

1 2th, I operated the fourth time* but with- 
out fuccefs. The needle always piifhed the 
cataract in part through the pupil, when I 
attempted to detach it ; but it returned imme- 
diately to its former fituation. No inflam- 
mation. 

20th, I couched my patient the fifth time, 
and then fucceeded in deftroying the adhefion* 
and removing the cataract. I could not per* 
ceive any part of it the next day ; but it after- 
wards rofe up gradually, and regained its 
place* 

Auguft 6th, I performed the fixth opera* 
tion. The cataract was again removed, and 

G appeared 



Sg On the Cataract. 

appeared no more. No inflammation fuper-* 
vened. The man was fhortly after difcharged 
cured. 

By this gentle procedure, I was enabled to 
deftroy a very ftrict adhefion of the cryftalline 
and its capfule to the iris, without injury to this 
delicate membrane. I am ftrongly inclined 
to believe, that had I, through fear of 
being foiled in an operation, broken down 
the adhefion at once, I mould have fent my 
patient home in total darknefs : whereas I had 
the pleafure of feeing him reftored to as per- 
fect a degree of light, as is ufually enjoyed with 
the lofs of the cryftalline humour. 

It leems as if the cryftalline, though not 
opake itfelf, had adhered to the opake capfule. 
It is alfo worthy of obfervation, that the cap- 
fule had fpontaneoufly regained fome trans- 
parency, in its central part, after having re- 
mained in an opake ftate during twelve 
years. 

CASE IV. 

Total Adhefion of the Iris to the CataraB. 

In October 1800, Mr. James Holgate of 
Hawkefworth, woolftapler, aged twenty-one 
years, was brought to me by his father, on 

account 



On the Cataract. 83 

account of a lofs of fight, and gave me the 
following hiftory of his cafe. 

About a year and a half before this confu- 
tation his eyes became inflamed, and his fight 
began to diminiih. The diminution of fight 
encreafed gradually during the courfe of a 
year, till he became lb blind, that he could 
merely perceive a glimmering of light, or a 
bright red colour; but could diftinguifti no 
object. In that ftate he had continued for 
half a year without any amendment. 

The capfula of the cryftalline humour was 
uniformly opake, and of a white colour. It 
adhered univerfally to the iris, fo that there 
was not the leaft perceptible alteration in the 
fize of the pupil upon varying the degree of 
light to which the eye was expofed. Both 
eyes were in the fame ftate. They were ra- 
ther prominent, but were not now in an in- 
flamed ftate. 

I informed the young man and his father, 
that I could not entertain much hope of a cure 
in fuch a cafe as this ; but that, if the young 
man w^as defirous of fubmitting to an opera- 
tion, under fuch a ftate of uncertainty, I would 
do every thing for him which w T as in my pow T ei\ 
I informed them alfo, that as the operation 
could not well diminiih his fight; fo neither 

G % was 



8% On the Cataract. 

was it likely to injure the appearance of hii 
eyes. There was a poffibility of its proving 
in fome degree beneficial. The young man 
Was very defirous that I mould make an at- 
tempt to feftore to him fome degree of fight, 
if there was but a poffibility of doing him 
good by tile operation. 

After keeping my patient a few days on 
flender diet, and giving him a gentle laxative, I 
operated on both eyes; but found the adhefion 
of the capfula to the iris fo firm, that I could 
not make an evident feparation in any part* 
without ufing more force, and continuing my 
efforts longer, than I judged to be prudent. 

Notwithstanding this failure, my patient 
was not difcouraged. He had felt lefs pain 
from the operation than he had expefited; and 
having no inflammation in his eyes after it, 
excepting a flight degree of tendernefs, he was 
delirous that I mould renew my attempts, as 
foon as I fhould judge another operation to 
be proper. 

Upon repeating the operation, his percep- 
tion of light was a little increafed, though I 
could not difcern any decided feparation be- 
tween the capfula and iris. 

Encouraged by a gradual amendment, and 
the trifling degree of tendernefs in the eyes, 

which 



On the Cataract. 85 

which fucceeded each operation, I purfued my 
plan with fteadinefs, at the earneft folicitation 
of my patient, and repeated the operation, 
about once a month. 

After the fifth operation he could difcern 
the pointers upon the face of his watch, when 
he placed it in certain pofitions, fuited to the 
breaches which were now made in the cap- 
fula. 

Thefe breaches were gradually enlarged ; 
feut fome operations were more fuccefsful than 
others. The eighth encreafed much the fphere 
of his vifion ; but the eleventh made a greater 
alteration than any which had preceded. By 
this operation the greateft part of the capfula 
\n the right eye was removed, and that of the 
left eye was confiderably detached. 

He had before this time walked without a 
guide in a private yard adjoining to the hpufe 
where he lodged ; but his fight was now fo 
much improved, thafr he was abl§ to walk 
alone through the crowded ftreets. of Leeds. 

After the twelfth operation, I advifed him 
to return home, and to wait for fome months 
the event of thefe attempts to reftore his fight. 
He complied with this advice, though .with .fome 
flegree of relu&ance, having received fo much 
benefit from the operations, and being defirous 

G 3 of 



8'S On the Cataract.- 

of obtaining as foon as poffible that accurate 
light which his bulinefs required. Whether 
this will ever be obtained is a matter of fome 
doubt ; but the advantage and comfort which 
he now enjoys are not inconfiderable. 



ASE V. 



Fragments of the Capfule coalefcing\ 

In May 1 76 9 5 Ruth Powell was received 
into the Infirmary for a cataract of the right 
eye. The left had been couched eight months 
before by an itinerant oculift, who punctured 
the cornea (as I was informed) to let out the 
aqueous humour rendered turbid by the opera- 
tion. The fubfequent inflammation had caufed 
an obliteration of the pupil. 

I depreffed the cataract very readily with ^ 
round needle, and it did not reafcend ; yet 
my patient received very little benefit from, 
the operation, Upon examining the eye a few 
days afterwards, the capfule was found to have 
become opake, though it was tranfparent at 
the time of the operation, I had punctured 
it with my needle ; but the puncture having 
been made below the centre of the pupil, the 
rays of light could not fall upon the retina^ 

except 



On the Cataract. 87 

except when the pupil was largely dilated. 
When the pupil was much contracted in a 
ftrong light, fhe could difcern no object, for 
the iris then covered the broken part of the 
capfula. 

The inflammation which fucceeded this 
operation was fo trifling, that (he walked about 
the ward, with her eye uncovered, before the 
expiration of a week^. 

I performed a fecond operation, a fortnight; 
after the former, with a view of tearing in 
pieces the remains of the capfule, or at leaft, 
of enlarging the aperture which I had before 
made in it. The reilltance given to the 
needle by that delicate membrane, floating in 
the aqueous humour, was fo fmall, that I 
found it difficult to tear off any part of it, and 
impoffible to remove the whole. The attempt, 
however, was not unfuccefsful ; for her light 
was fo much improved by it, that fhe was 
enabled to follow her ufual employment with-: 
put difficulty. 

She continued to enjoy diftincl vifion for 
two or three years, and then began to com- 
plain of fome dulnefs in her fight. I exa- 
mined her eye, and obferved, that the remain- 

* I mention this as a fact, but I do not recommend., 
nor ufually permit it. 

G 4 ing 



$8 On the Cataract. , 

ing fragments of the capfule, which had hung 
loofe, and left an "aperture alrnoft as large as 
the pupil in a moderate light, now formed two 
fmall tranfverfe threads, which rendered vifion . 
fomewhat indiftinct. I adviied a repetition 
of the operation, and at firft me feemed de- 
firous of it; but finding that me could ftill 
execute her bufinefs tolerably, fhe deferred 
procuring a re-admiffion into the Infirmary, 
and finally remained fati&fied with the advan- 
tage me had received. 

It is difficult to conceive how fuch a coa~ 
lefcence of the fmall and floating fragments 
of the capfula, as I have defcribed, could 
happen, 

CASE VI. 

- i 

Temporary Amaurojis from Inflammation, 

May 28th, 1772, I couched both the, 
eyes of Sarah Newfome. The fubfequent in- 
flammation was trifling, and difappeared the 
third day. June 12 th, I repeated the ope- 
ration on the left eye, and performed a third 
operation the 25th of the fame month. The 
two latter operations were followed by no 
greater inflammation than the firfL 

The 



• On the Cataract. 39 

The cataraft in the right eye, which had 
been broken at the firft operation, difappeared 
fo faft, that no repetition was required. 

When fiie could diftinguifti objects in the 
fields before the Infirmary with the right eye, 
fiie was difmiffed, with directions to return in 
about a month, that her eyes might be exa- 
mined. 

Upon her return I was furprized to find, 
that fhe had loft that degree of light in the 
right eye, which fiie enjoyed when (he left the 
Infirmary. Yet the catara6l had not appear*- 
ed again ; nor was there any opacity to be 
perceived in the cornea, or capfula of the cry- 
ftalline. The pupil was too much dilated, 
and the iris did not contract upon expofing 
the eye to a pretty ftrong light. In ftiort, 
the eye appeared to be affected with an amau- 
rojis. 

Upon inquiring into the caufe and progrefs 
of this unexpected complaint, the patient in- 
formed me, that in returning home, when dif- 
mined from the Infirmary, fiie had caught 
cold, which brought on an inflammation in 
the right eye, and a gradual lofs of fight. The 
rednefs of the conjunctiva had nearly difap- 
peared ; but fhe ftill felt a tendernefs of the eye. 

From 



90 On the Cataract. 

From a confideration of thefe -circumftances, 
I was led to fufpect, that -the complaint was 
of an inflammatory nature, and accordingly I 
ordered her to be bled immediately, and di- 
rected a purgative to he taken the following 
morning. Thefe means afforded the wilhed-* 
for relief," arid the eye was reftored to its for-^ 
mer ftate. 

I faw this patient February 17th, 1799, 
twenty-feven years after the operation, and 
fhe then enjoyed her fight as completely as 
|he]qis of tire cryftalline humour will admit*, 

CASE VII. 

CataraEt rifing again. 

In 1770, Ann Jenkins was admitted a pa- 
tient of the General Infirmary for a cataract 
in one eye, the cryftalline of the other being 
alio flightly opake. I depreffed the cataract 
without any conliderable difficulty. On ex- 
amining the eye two days after the operation, 

# Spectacles are generally neeefTary for thofe who. 
Lave loft the cryftalline humour. I have had fome pa- 
tients, who, when firfl reftored to fight, have been un- 
der the neceffity of joining two pairs of fpectacles for a 
time, and afterwards have been able to fee well with 
one pair. 

I per-> 



On the Cataract. 91 

I perceived the cataract to be in its former 
fituation. 

When the tendernefs of the eye was rer 
n^oved, the operation was repeated, and at 
my firft examination the eye had a good ap- 
pearance. The patient alfo found her fight 
reftored. But as the tendernefs of the eye 
decreafed, the cataract rofe again, till it came 
nearly into its original fituation. She was 
now made an out-patient, and about a fort- 
night after fhe had left the houfe, (lie became 
fenfible of fome amendment in her fight, and 
came to me requesting that I would examine 
her eye. I obferved that the cataract had 
already began to fubfide. In a fhort time 
afterwards it difappeared, and fhe regained 
her fight, * 

CASE VIIL 

Secondary Catarabl* 

In October 1780, I couched both the eyes 
of a girl, eight years old, the daughter of 
^Villiani Myers of Stainburn. The cataracts 
were foft, and permitted the needle to pafs 
through them in all directions, without re- 
moving them from their place in the vitreous 

humour. 



92 On the Cataract. 

Rumour. They appeared a little broken ; but 
no part was made clear by the operations,. 
The eyes remained tender, but no inflamma- 
tion fupervened. I fent her home to wait 
fome months before I fhould repeat the ope- 
ration. 

In June 1781, me came again under my 
care. She now could fee very well with the 
right eye. The capfula of the cryftalline x 
which I had ruptured at its centre with the 
needle, was retracted on all fides towards its 
attachment at the circumference of the cry- 
ftalline. There was an aperture left as large 
as the pupil in a ftrong light ; but in a mode- 
rate light, the remainder of the capfula ap-* 
peared all around, juft within the edge of the 
iris. 

In the left eye, the broken fragments of the 
capfula adhered to each other, fo as to prevent 
the direct rays of light from falling upon the 
retina. She could, therefore^ fee no object 
diftinctly with the left eye. 

. I did not think it neceffary to run any 
rifque, by attempting to enlarge the field of 
vifion in the right eye ; but I removed the 
opake capfula in the left eye, which readily 
yielded to the prefliire of the needle. Having 
laid hold of the capfula near its centre, wher$ 

it 



On the Cataract. 9$ 

it formed fome tranfverfe opake threads 5 I 
found it to be more firm there than at its cir- 
cumference, for the whole of the capfula was 
removed at one effort. 

The cryftalline humour feemed to have been 
dhTolved fince the former operation ; for I 
could difcern nothing opake except the 
capfula* 

The operation was attended with very little 
pain, and no inflammation fucceeded. The 
patient faw well, and could bear a ftrong light 
within a fortnight after the operation. 

I faw this patient in 1782. A fmall por- 
tion of the capfula, which I had removed ap- 
peared towards the external canthus of the 
eye ; but it projected fo little, that it feemed 
to afford no hindrance to diftinct vifion. 

Since the restoration of light in the left eye T 
(he had begun to fquint a little with the right, 
in which there remained a circle of opake cap^ 
fula, as above mentioned. 

CASE IX. 

Cure obtained by making the Needle pafi 
through the Cataract. 

A child of two years old was admitted into 
the General Infirmary, on account of a con- 
genital 



94 On the Cataract. 

genital catara6l in each eye. She could dife 
cern a glaring light, as a lighted candle, or 
burning coal ; and could alfo, in a ftrong light, 
difcern fome of the moll vivid colours. The 
motion. of her eyes was ufually parallel ; but 
me often placed them for a ihort time in dif- 
ferent directions, as if (he was looking at two 
diftinct objects. She rolled them about much, 
which made her fometimes appear like an 
ideot, though fhe was a very fenfible child. 
She was often moving her hand with rapidity 
before her face, when placed oppofite a win- 
dow, and delighted to blow out a candle, and 
do other fimilar tricks, that made a variation 
in the fight which fhe poffeffed. 

I attempted to couch her left eye, but was 
repeatedly prevented by the difficulty of hold- 
ing her fteady, and by the power which fhe 
had of retracting her eve within the orbit, and 
thereby rendering the conjunctiva flaccid. 
She could do this in fo great a degree, as 
fometimes to hide the whole of the cornea by 
the wrinkled conjunctiva, which then lay in 
folds before it. I once fucceeded fo far. as to 
penetrate the eye witji my needle, and juft 
move it through the cataract ; but her wriggling 
motion made any continued attempt to deprefs 
the cataract fo hazardous, that I was glad to 
^ J withdraw 



On the Cataract. 95 

withdraw my inftrument without doing any 
injury to the eye. 

The child was difmiffed till a more advan- 
ced age fliould render the operation lefs ha- 
zardous. 

About three years afterwards, being in the 
neighbourhood of the child's parents, I looked 
in upon them for the purpofe of feeing the 
child, and was agreeably furprized to find the 
left eye, into which I had introduced my 
needle, almoft clear. The restoration of the 
child's fight (for it was now in part reftored) 
had been fo gradual, that her parents could 
not inform me of the time when (he began to 
difcern objects. 

The rolling, motion of the eyes ftill con- 
tinued. 

CASE X. 

Pain above the Eye-brows. 

In 1799, I couched the right eye of Mrs. 
Spotfwood of Lincoln, an elderly lady. The 
night after the operation fhe complained of 
much pain in the forehead, juft above the eye- 
brow, attended with iicknefs at the ftomach ; 
but there was no appearance of inflammatory 
affection in the eye. I gave her a gentle laxa- 
tive, 



§6 On the Gat Ait a cf. 

tive, and after that an opiate, which removed 
the painful fenfation, and the ficknefs. Her 
cafe required a repetition of the operation. I 
couched her eye foiir times before the opake 
portions of the capfule were fufficiently re* 
moved. The pain* which had affected her 
after the firft operation, never returned, nor 
did the le&ft inflammation fupervene. After 
the three latter operations, flie informed me 
that the pain caufed by the puncture ceafed 
fo foon, that me felt no uneafinefs after I 
had left the room in which I had operated* 
Indeed the uneafinefs ceafed almoft as foon as 
I had withdrawn my needle, and did not re« 
turn. 

The year following this lady favoured me 
with a letter, very well written by her own 
hand. 

Opiates have always, as far as I can recol- 
lect, relieved the complaints above-mentioned* 
even when they have been accompanied with 
fome inflammatory affection of the eyej 

This lady's cafe was by no means a favour- 
able one, as there was too great a contraction 
in the pupil previous to the operation ; fo that 
I confidered the fuccefs as more doubtful 
than ufuaL The left eye was in fo morbid a 
It ate, that I did not operate upon it, 

CASE 



On the Cataract. 97 

CASE XL 
Contracted Pupil. 

In September 1793, Mr. Champley of 
Thornton, near Pickering, aged feventy-two 
veirs, confulted me on account of a lofs of 
light in both eyes. 

The left eye appeared to be affected with 
an amaurofis, the right eye with a cataract. 
He could not diftinguifh one perfon from an- 
other, nor was he able to walk abroad without 
fome perfon to conduct him. 

The right eye was by no means in a favour- 
able ftate for the operation, as the pupil was 
much contracted, and the iris almoft immov- 
able. A very flight motion of the iris might 
be perceived upon expofing the eye fuddenly 
to a ftrong light. . In the twilight he had a 
fmall perception of light with this eye ; but 
in a ftrong light the pupil was fo much con- 
tracted that he could fee nothing. 

I explained to my patient, and to his ne- 
phew, a fenfible young man who accompanied 
him, the nature of the difeafes with which his 
eyes were affected, and propofed the removal 
of ths cataract in the right eye, though my 

Et hopes 



98 On the Catakact. 

hopes of fuccefs were not fanguine. How** 
ever, as a failure in my attempt to reftore the 
fight would not make his condition to be 
worfe, my patient confented to the operation. 

The great difficulty in this cafe was, to 
know when the point of my needle was 
brought into a proper place for depreffing the 
cataract, as I could not fee the inftrument 
through the pupil. The fhortnefs of my 
needle greatly affifted me in this dilemma. 
When I had introduced it as far as I judged 
proper, I brought forwards its point towards 
the pupil ; and obferving that in this motion 
the cataract was made to advance, and dilate 
the pupil, I was certain that the inftrument 
was then preffing upon the pofterior part of 
the cryftalline, in which its point might now 
probably be entangled: I therefore turned 
the point backwards, and had the pleafure to 
fee the cataract carried away by it. The ca- 
taract difappearing as I deprefled the point of 
my needle, I turned the point backwards to- 
wards the outer canthus of the eye, and then 
withdrew the needle in a direction parallel to 
the axis of the pupil. 

Mr. Champley had very little uneafmefs 
after the operation, but was anxious to return 
home, as he apprehended he had received no 

benefit 



On the Cataract. 99 

benefit from the operation. I could not pre- 
vail upon him to ftay longer than a week at 
Leeds. Before his return, I procured fome 
cataract fpectacles, and requefted him to 
make a trial of their ufe. He was furprized to 
find, that by the affiftance of a pair mode- 
rately convex, he could diftinguifh the faces of 
the perfons in his room, and defcribe their 
drefs. He could alfo diftinguifh capital let- 
ters in the title page of a fmall dictionary, 
which lay upon the table. He difcerned the 
fmall figures in a paper with which the room 
was hung, but miitook a little the colour of 
the ground of the paper. In feveral trials 
which I made, I found that he could diftin- 
guifh figures better than colours. 

Before I conclude my obfervations on the 
Cataract, I fhall take fome notice of the ob- 
jections which Baron Wenzel has made againft 
the operation of couching, and then contraft 
the inconveniences of this operation with 
thofe which he allows to arife from the me- 
thod of extraction. I judge this comparifon 
the more neceffary, as I have already ob- 
ferved, becaufe Mr. Ware, the tranflator of 
theBaror/sTreatife, feems to coincide intirely 
with his author in thefe objections ; and be- 
ll 2 caufe 



100 On the Cat Ail act. 

v eaufe I know that many furgeons confider 
the practice of couching as obfolete, and 
greatly inferior to that of extraction. 

The Baron treats this operation with fome 
contempt. " I think it unnecefTary," he fays, 
to enter further into an explanation of the 
different modes of depreffing the cataract* 
lince this operation is at prefent almoft 
*' univerfally exploded/' 

Ware's Tranflation, p. 18. 
He begins his Section on the accidents pro* 
duced by couching, with this obfervation, that 
u the objections againft couching are infi- 
" nitely greater, and the effects of it much 
46 more to be dreaded," than thofe of extrac- 
tion. He then enumerates the following ac- 
cidents to which the operation is liable. 

lft. " The pain is fevere during the 
u operation." On this head I have given 
the language of one lady* (the late Mrs. 
Scott of Leeds) who was afked concerning 
the pain immediately after I had operated. 
The account which me gave may be con- 
iidered as a fair fpecimen of the pain attend- 
ing the operation in general. There is un- 
doubtedly a difference in the fenfibility of dif- 
ferent perfons ; and fome patients may ex- 
prefs a greater fenfe of pain on account of a 

greater 



* Page 63. 



On the Cataract. ioi 

greater difficulty in removing the cryftalline 
or opake capfula ; but patients frequently ex- 
press furprife at the fmall degree of pain 
caufed by the operation, and rarely fpeak of 
it as a very painful one. The fmcerity of 
their expreffions is confirmed by the readi- 
nefs with which they fubmit to a repetition of 
the operation, and not unfrequently by a re- 
queft for fuch repetition. 

2dly. " The vomiting, which frequently 
" comes on at the diftance of fome hours 
" after the operation, is apt to produce a coi- 
" lection of matter in the eye." I fhall re- 
ferve what I have to fay on collections of 
matter in the eye, till I anfwer the third ob- 
jection, in which this confequence is attri- 
buted to the puncture of the retina and cili- 
ary nerves. With refpect to the vomiting, 
which is here faid frequently to occur, my 
anfwer is, that it does not frequently occur ; 
and whenever it has occurred in any of my 
patients, it has been fpeedily removed by an 
opiate. 

3dly. " The pain produced by the punclure 
" of the retina and the ciliary nerves, is often 
" followed by a fuppuration of the eye." 

I have now praftifecl the operation of 
couching pretty frequently for thirty-three 

H 3 vears, 



102 On the Cataeact. 

years, though I have not kept a lift of all the 
patients upon whom I have operated. I have 
alfo feen the operation performed frequently 
by my colleagues at the Leeds Infirmary ; 
but never yet faw an inftance of a fuppuration 
of the eye, in any patient who has come 
under my care in private practice, nor in any 
cafe that has occurred at our public hofpital. 

4thly, " Thofe perfons who have under- 
" gone the operation of couching, fometimes 
" feel conftant and violent pains in the eye 
" as long as they live/'' 

In this objection I leave the Baron to judge 
by his own experience. I never knew this 
confequence to follow from the operation in 
any of my own patients. An old woman was 
admitted into the General Infirmary at Leeds, 
on account of a cataract in each eye, accom- 
panied with a chronic ophthalmy. She re- 
mained feveral weeks in the houfe, before the 
ophthalmy could be fo far removed as to make 
it advifable to perform the operation for re- 
moving the cataracts. When the inflamma- 
tory affection feemed to be fubdued, the ope- 
ration was performed with fuccefs, and the 
poor woman continued in a comfortable ftate 
for about ten days. The ophthalmy then 
returned, and could never afterwards be com- 
7 • pletely 



On the Cataract. 103 

pletely fubdued. A great variety of means 
were ufed with temporary advantage, but this 
was always followed by a relapfe, which often 
came on fuddenly, without any apparent caufe, 
I was at laft obliged to fend my patient home 
with an incurable ophthalmy. This is the 
only inftance of the kind which has occurred 
to me, and which could not be attributed to 
the operation, as it had fubfifted a long time 
before Ihe came under my care. This is a dif- 
ferent cafe from the lippitudo, where the 
veffels of the conjunctiva are turgid, and the 
eye-lids thickened, without any acute inflam- 
mation. 

5thly. " In introducing the couching needle, 
" the blood veffels, both of the choroides and 
" retina, are liable to be w^ounded, and the 
extravafated blood not only confufes the 
fight of the operator, but, unlefs fpeedily 
abforbed, is very apt to produce a fuppura- 
\\ tion of the whole eye/" 

I have often punctured the blood veffels of 
the conjunctiva, but in this cafe, the blood, 
which feldom exceeds a drop or two in quan- 
tity, is always difcharged upon the globe of 
the eye. I do not recollect a cafe in which 
I perceived any blood to flow from within, fo 
as to mix with the aqueous humour. But if 

H 4 this 



104 On the Cataract. 

this accident mould occur, the operator may 
withdraw his needle, and poftpone the remain- 
ing part of the operation. 

6thly. " The foft and milky cataract can- 
** not be depreffed by the needle ; nor can 
" the needle be employed in fuch a cafe with 
u any profpect of fuccefs." 

This objection is not founded in fact, as I 
could bring abundant teftimony to prove, if 
it were neceffary. The foftnefs of the cataract 
generally requires a repetition of the opera- 
tion, but does not prevent the patient from 
receiving a cure. A foft cataract has in fome 
refpects the advantage over a hard one, as the 
former is lefs apt to adhere to the iris; and 
eonfequently there is lefs rifk of deranging the 
ciliary proceffes, or their inverting membrana 
nigra, by breaking down a foft cataract, than 
by removing a hard one. 

In the clofe of this objection the Baron 
denies, " that the milky cataract, when placed 
* in the anterior chamber, will gradually dif- 
" folve and difappear." 

It frequently happens, that portions of a 
foft cataract fall through the pupil into the 
anterior chamber of the eye, and fometim.es 
the whole of a folid opake nucleus. In every 
cafe m which either of thefe accidents has 

• occurred. 



On the Cataract, 105 

occurred, the opake portions have gradually 
diffolved in the anterior chamber, and have 
finally difappeared without any injury to the 
eye. I am fo well convinced that this eonfe- 
quence may be expected, that if I could 
make the cataract pafs, in every cafe, into the 
anterior chamber, without injury to the iris, 
I fhould prefer this method of terminating the 
operation to any other. I. will not fay, that 
the cryftalline always becomes diffolved when 
placed in the inferior part of the vitreous hu- 
mour ; but this is of no confequenc^, if it 
never appears again to obftruct the rays of 
light which pafs through the pupil. 

7thly. " After the cryftalline humour has 
" been de pre fled in the beft manner poflible, 
" it is liable to rife again." 

This objection is true, but of little confe- 
quence. A repetition of the operation is not 
in this cafe always neceffary, as the cryftalline 
will fometimes fpontaneoufly fubfide and difap- 
pear (fee Cafe VII.) and when it does not, a 
repetition of the operation has never failed, 
within the compafs of my experience, of being 
attended with fuccefs, 

Sthly. " The ciliary proceffes, which furround 
" the cryftalline, are liable to be wounded by 
iC the different movements of the needle." 

This 



106 On the Cataract. 

This objection applies chiefly to the fpeais* 
fhaped needle, in which the point projects 
beyond that part of the inftrument by which 
the depreffion is effected. This inconveni- 
ence is obviated by the form of the needle 
which I have above recommended. In the 
ufe of this inftrament the cryftalline is depref- 
fed by its extreme part, which alone is iharp 5 
though not pointed, and which need not be 
brought into contact with the ciliary proceffes. 
The ciliary proceffes are in the greateft dan- 
ger from the adhefion of a firm cryftaUine or 
opake, capfule, and are equally liable to be 
deranged by the removal of the difeafed part 5 
whether the operation is performed by extrac- 
tion or depreffion. . 

9thly. In the fifth Section of the Baron^s 
Treatife it is afferted, that " the cafe of an- 
" opaque capfule of the cryftalline is entirely 
c? out of the reach of the operation of couch- 



" mg. 

nrii 



The cafes which I have related have already 
fhewn the fallacy of this obiection. 1 have 
thewn that the needle may be ufed with fuc- 
cefs> not only in the cafe of a fimple opake 
capfule, which is often removed with as 
great eafe as the opake cryftalline, but alfo 
when there is a partial, or even a total adhe^ 

lion 



On the Cataract. 107 

fion of the capfule to the iris; though fome of. 
the advocates for the operation of couching 
have feemed to give up this laft cafe in cle- 
fpair. 

If an opake and adherent capfule could 
always be removed with fafety, by a fingle 
operation of extraction, I mould readily allow 
that, in this inftance, the operation would be 
fuperior to that of couching. But, " notwith- 
',' ftandingafewinftances of fuccefs," the Baron 
himfelf allows that his operation in this cafe is 
of very doubtful event. " If the opaque capfule 
t* adheres to the iris, and an attempt to ex- 
fj tract it be perfiftecl in, there is danger of 
" feparating the iris from its connection at the 
" outer margin, and inducing blindnefs from 
" this caufe." p. 26. 

1 Othly. A tenth objection againft couch- 
ing occurs in the iixth Section, where the 
Baron is examining the objections againft ex- 
traction, " A fecondary cataract, by which 
" I mean an opacity of the pofterior cap- 
" fule of the cryftalline lens, takes place 
" much oftener after the operation of depref- 
9 fing the cataract, than after that of .extract- 
" ing it." p. 25. 

What reafon the Baron has for fuppofing 
that it is the pofterior, rather than the ante- 
rior 



108 On the Cataract. 

rior capfule of the cryftalline, which forms 
the fecondary cataract, I cannot tell. I am 
of opinion, with Mr. Ware, that the anterior 
portion of the capfule is generally the feat of 
this difeafe. So it has appeared to me in 
operating for the fecondary cataract. It is 
not in my power to determine whether this 
difeafe takes place " much oftener after the. 
C£ operation of depreffing the cataract, than 
** after that of extracting it." Neither can 
the Baron determine this, I mould fuppofe, 
from his own experience. The fecondary ca- 
taract does certainly follow both methods of 
operating ; and if it does not fpontaneoufly 
difappear, a repetition of the operation be- 
comes neceffary in both methods. When the 
opake capfule has been broken, and hangs in 
fragments from its circumference, it is often 
difficult to tear off thefe pieces, as they give 
fa little reliftance to the needle. This I think 
to be the principal difficulty, which the ope- 
ration of couching has to overcome. Yet a 
cautious repetition of the operation will rarely 
fail to make fuch an aperture in the capfule as 
feall enable the patient to read with glaifes, 
and confequently to enjoy his light for pur- 
pofes of lefs difficulty. 

llthly. 



On the Cataract. 109 

Uthly. " A total clofure of the pupil is a 
misfortune which rarely happens after the 
operation of extraction, but much more 
frequently after that of couching." p. 24. 
I have feen this confequence from the ope- 
ration of an itinerant oculift ; but it has never 
occurred in my own practice, nor have I ever 
feen an inftance of it after any operation per- 
formed by my colleagues at the General Infir- 
mary. 

I have now confidered every objection of 
confequence urged by Baron Wenzel againft 
the operation of couching ; and fhall proceed 
to examine thofe which he allows to lie againft 
that of extraction. 

1. The Staphyloma is one confequence of 
the operation of extraction, from which that 
of couching is entirely free. By this term 
Baron Wenzel means a projection either of a 
tranfparent membrane, (concerning the nature 
of which the Baron and his tranflator differ 
in opinion) or of the iris through the wound 
made in the cornea. This accident is allowed 
to happen fometimes " under the beft ma- 
'* nagement," p. 240. I fhall take no farther 
notice of the tranfparent ftaphyloma, firice it 
is reprefented as a curable complaint. But is 

it 



110 On the Cataract. 

it poffible to conceive, that the interior edg© 
of the iris can be drawn fo far from its proper 
fituation, as to the exterior part of the cornea, 
and remain there^ without injury to the pa- 
tient ? With refpect to the deformity which 
this accident occaiions, let the reader confult 
Sir James Earle's late publication on the 
cataract, in which he will fee the fketch of an 
eye fo deformed. 

From this authors account it will appear, 
that in one inftance at leaft, this fpecies of 
ftaphyloma was accompanied w r ith blindnefs, 
I leave to the abettors of extraction to prove, 
that it ever happens without fome degree of 
inconvenience to the patient. 

2. The lofs of the vitreous humour, in whole 
or in part, is another and not unfrequent con- 
fequence of the operation by extraction. And 
though this accident may not always prove 
injurious ; yet it is allowed fometimes to di- 
miniih, and fometimes to deftroy the fight of 
the patient, " In fome patients, even a con^ 
" fiderable effulion has not prevented the fuc- 
c * cefs of the operation ; though in others, it 
" mud be owned, this accident has much 
" diminished the clear perception of objects." 
p. 23. Again, " She fubmitted to have one 

cataract extracted by an oculift of that 

city 






On the Cataract. i i 1 

city" (Paris) " but without the fmalleft fuc- 
cefs ; and the failure I imputed to the efcape 
of almoft the whole of the vitreous humour, 
together with the cryftalline." p. 192. 
In one cafe which the Baron relates, there 
was a lofs of three-fourths of the vitreous hu- 
mour, notwithftanding which the patient re- 
gained her fight; but his remarks on this 
cafe mew clearly the danger of fuch an acci- 
dent. " I could not refrain from giving up 
" the eye as entirely loft." p. 169, Note. 
Again, " To my great furprize, me diftin- 
" guimed every object me looked at, which, 
" conlidering the accident, was almoft in ere- 
" dible." p. 170. 

In another cafe, " the violence of retching/' 
which immediately fucceeded the operation, 
" caufed an extravafation of the vitreous hu- 
" mour, and, in confequence of this, a total 
" lofs of fight/' p. 162, Note. 

Mr. Ware agrees with the Baron in allow- 
ing the injury which arifes from the difcharge 
of the vitreous humour. He fays, " The 
" tranflator thinks it much fafer to leave thefe 
" minute fragments " (which may appear 
after the extraction of the crvftalline) " in 

" the 



1 1 £ On the Cataract. 



" the eye, than to hazard the ill confequences 
" which the difcharge of the vitreous humour 
" is too apt to produce/' p. 252, Note. 

The danger of an efcape of the vitreous 
humour is greatly increafed, when this hu- 
mour, through difeafe, acquires an unnatural 
fluidity; or when the pofterior part of the 
eapfule of the cryftalline is extracted. In the 
former cafe, the extraction of the cryftalline 
becomes extremely difficult, as " all preffure 
" on the ball of the eye muft be carefully 
" avoided/' p. 165. Yet with every care 
" a confiderable portion of the vitreous hu- 
" mour" may be loft. This happened in 
M. de Pradine's cafe, who yet regained his 
fight : but Mr. Ware's note on this cafe de- 
ferves attention: " The operation in this 
" inftance proved Angularly fortunate. But 
" the tranflator is of opinion, that it ought 
" not to encourage a fanguine hope of fuccefs 
" in fimilar cafes." p. 1 73, Note. 

With refpect to the extraction of the pofte- 
rior eapfule, the Baron urges great caution 
" not to touch the membrane of the vitreous 
"humour," and gives other cautions, " in order 
" as much as poffible to prevent the effulion 
" of the vitreous humour ; which, however, 
" it is in many inftances extremely difficult 
6 " to 



On the Cataract. 113 

;c to avoid." p. -264. Mr. Ware " believes it to 
" be utterly impoffible to engage and extract 
" the former" (the pofterior part of thecapfule,) 
" without at the fame time involving: the lat- 
" ter" (the membrane of the vitreous hu- 
mour). 

From all thefe difficulties the operation of 
couching is free. 

3. " Among the inconveniences to which 
the iris is liable during the procefs of this 
operation " (of extraction,) " I mall take 
notice of its feparation from the choroides 
in any part of its circumference, — — — 
** although this accident very rarely occurs." 
p. 208. In Madame Patin's cafe " the cornea 
" and capfule were fcarcely opened, when the 
" iris detached itfelf,inits inferior and outward 
" lateral portion, to the extent of about a 
" fourth part of its circumference." p. 209* 
Whenever this accident occurs, " the cryftal- 
" line always comes through the artificial 
" opening." p. 217. which cannot happen 
without a considerable laceration of the iris. 
A degree of deformity, at leaft, muft be the 
confequence of this accident (to which the 
operation of couching is not liable); but it 
induces the hazard of a much more ferious 
event, as the Baron acknowledges. For, 

I fpeaking 



On -the Cataract. 

dug of the opake adherent; capfule, he 
fays, " If the opaque capfule adheres to the 
" iris, and an attempt to extract it be per lifted 
a in, there is danger of feparating the iris 
"'from its connection at the-oiiter margin, 
" and inducing blindnefs from this caufe." 
p. 26 5 Note.- 

4. The clofure of the pupil is an accident 
which fometimes follows the extraction of the 
cryftalline. " This clofure of the pupil, which 
" is occafioned by the inflammation of the 
" iris, and by the fuppuration in which it 
" terminates, has always been confidered as 
" the molt grievous accident that can poflibly 
" take place, after the operation of extrac- 
" tion."" p. 266. For the cure of blindnefs from 
this caufe, the Baron has pointed out a method 
of making an artificial pupil, which, he fays, 
has been attended in fome inftances with fuc- . 
'cefs. But if " the inflammation ■ of the iris 
" terminates in fuppuration/" what can any 
operation effect ? It is but in fome favourable 
cafes that the operation can -poflibly fucceed 9 
as the Baron allows; for, " when the clofure , 
" of the pupil is occafioned by a violent oph- 
" thalmy" (which may be -.can fed by the ex- 
traction of the cryftalline,) ^ it rarely happens 
*' : that the organization of the eye is not other- 

< 4 wife 



On the Cataract. 115 

11 wife io much injured, as to deitroy all 
" hopes from any operation/' p. 277. 

I have already noticed, that thexlofure of 
the pupil has never followed any operation of 
couching which I have performed. 

5. I entirely agree with the obfervation of 
Baron Wenzel, that " whatever mode of per- 
" forming the operation may be adopted, and 
" whatever precautions may be ufed, we muft 
" not flatter ourfelves that pain and inflam- 
" mation can always be prevented." But I can- 
not accede fo readily to his affertion, Ci that in- 
" flammation and exceffive pain occur much 
" lefs frequently when the operation is con- 
" ducted in the manner he has recommend- 
" ed, than when it is performed in any other 
" way/' p. 223. 

We mail be able to form a juft judgment on 
this fubject, by enquiring into the frequency 
of the wprft effects produced by inflammation, 
in the different methods of operating. We 
have already purfued this inquiry with re- 
fpect to fome of the confequences of the dif- 
ferent operations, and it has hitherto been in 
favour of the operation by couching : let us 
now examine the worfl. confecruence that 
ever attends an attempt to reftore fight to 
perfons afflicted with the cataract. 

12 "The 



1 16 On the Cataract. 

" The 'moft formidable accident that fol- 

64 lows the operation of extracting the cata- 
" ract, is a violent inflammation of the globe 
" of the eye; during the continuance of 
u which, the conjunctiva becomes confide- 
" rably inflated, and the eye immerfed in a 
" large quantity of acrid matter. In confe- 
" quence of this, the cornea not unfrequently 
a becomes opaque, and purulent matter is 
" collected behind it ; the matter being feme- 
" times found in both chambers of the aque- 
" ous humour ; and from this caufe the pa- 
" tient fuffers excefiive and inceffant pain. If 
" the remedies that are ufually directed in 
" cafes of inflammation be infuftleient to pro* 
" duce an abforption of the matter, which in- 
" deed too often happens, the cafe is hope- 
" lefs ; and the pain will not ceafe until the 
" fuppuration is complete, and the eye funk 
" and loft." p. 23.1. 

I admire the candour of the Baron in thus 
ftating what he has feen, and am glad to read 
the fentence- which follows his defcription of 
this formidable accident that fometimes at- 
tends the oneration of extraction. " I am 
" happy to fubjoin, that it very feldom oc- 
• 4 curs in the courfe of our practice/' p. 232. 
I am alio happy to be abl$ to fubjoin, that in 

my 



On the Cataract, 117 

my practice it has never yet occurred. The 
Baron does not make the fame declaration 
with refpect to the following accident, which 
is nearly allied to the former. " Again, a 
" collection of purulent matter is fometimes 
" formed in the eye within a few davs after 
" the operation, without any external fymp- 
" toms of inflammation, and without being 
" preceded by any remarkable fenfations of 
" pain/' lb. 

I have ken inftances of inflammation, fome- 
times, though not often, confiderable in de- 
gree ; but in no one inftance has the inflam- 
mation been attended with, or followed by, 
a collection of purulent matter or a fuppura- 
tion of the eye. 

Before I committed thefe obfervations to 
the prefs, I wrote to my late colleague Mr. 
Lucas, now retired from buiinefs, who was 
furgeon to the General Infirmary at Leeds, 
from its inftitution in 1767 to the year 1793, 
and propofed to him fome queries refpecting 
the effects of couching. He favoured me with 
an anfwer in the following terms : " I do not 
" recollect, either in public or private prac- 
" tice, having ever feen a fuppuration taking 
" place in the eye, the pupil becoming clofed 

and obliterated, or the fight having been 

13 " deftroyed 



118 On the Cataract. 

*' deftroyed by a fucceeding opacity of the 
" cornea, that could be afcribed to the ope- 
ic ration of couching." 

I have now confidered the objections made 
by Baron Wenzel to the operation of couch- 
ins;, and alfo thole which he allows to lie 
againft that of 'extraction. Other objections 
againft the latter, and thofe of considerable 
weight, may be found in fome modern writers 
on furgery ; but I have thought it the moft 
fair method' of canvafling this Subject, to con- 
fine rnyfelf to the facts which are ftated in the 
Baron's Treatife. I have no wifh, but that 
that mode of operating may prevail, which is 
the moil beneficial to the afflicted, 



[H9] 

CHAR III. 

Of the Strangulated Hernia. 

THE Strangulated Hernia is a frequent 
difeafe, and one which requires great and 
Ipeedy attention. Perfons airlifted with rup- 
tures are numerous. The prolapfed parts are 
often in a painful and irreducible ftate for a 
few hours, and then retire without any bad 
confequences. On this account patients often 
permit them to remain in this ftate much too 
long without calling in proper affiftance. 

When a medical perfon is confulted, the 
difeafe is fometimes concealed, either from 
modefi;y, or from the pain being lefs in the 
rupture than in other parts of the abdomen, 
which is fometimes the cafe ; the patient hav- 
ing no appreheniion that pain at the navel or 
ftomach, with frequent vomiting, can be caufed 
by a fmall fwelling in the groin. This con- 
cealment happens the mod frequently in the 
female fex, and is fometimes carried to an ex- 
treme ; fo that I have more than once known 
the patient deny the exiftence of the difeafe. 
On this account I have made it a rule for many 

i 4 _years 3 



120 Strangulated Hernia. 

years, always to examine thofe parts of the 
abdomen which are the ufiial feat of a hernia, 
whenever I am called to a patient labouring 
under the Ileus. For want of this precaution, 
the ftrangulated hernia may prove fatal, by 
being miftaken for a Ample ileus. Such mif- 
takes I have knpwn to happen. Indeed, in 
the femoral hernia the tumour is fometimes 
fo fmall, and free from external inflammation, 
or tenfion of the integuments, that there is 
danger left the furgeon, without a careful in- 
quiry into all circumftances, mould miftake 
the rupture for an enlarged inguinal gland*. 

When, the nature of the complaint is clearly 
afcertained, the danger is often increafed by 
continuing: too long; the ufe of thofe means 
which are defigned to procure a reduction of 
the ftrangulated inteftine. The complaint is 
fometimes, indeed, fo rapid in its progrefs, 
that the patient is fcarcely alarmed with his 
danger before the difeafe is irremediable. But 
in. all cafes, it is of great cpnfequence to make 
choice of fuch means, for producing a reduce 
tion, as will take effect in a lliort time, or will 

# Mr. Elfe found a portion of inteftine ftrangulated 
in the groin, behind an enlarged gland, in a patient who 
died the third day of the ftrangulation. 

Med. Obf. & Inq. vol. iv. p. S55. 

foon 



Strangulated Hernia. 121 

ibon determine that reduction is impractica- 
ble. A ftrangulated hernia often retires fpon- 
taneoufly, or with the flighted affiftance, and 
fometimes after the difeafe has continued 
many days ; but if we fuffer our expectation 
to be raifed much by fuch favourable events, 
we mall often bring on that fatal termination 
which might otherwife have been prevented. 

No mode of treatment has hitherto beea 
difcovered, which will certainly procure a re- 
duction of the ftrangulated hernia, without 
having: recourfe to the knife. Writers on this 
difeafe feem to have confidered the treatment 
which they have recommended, as appropri- 
ated to all fubje&s labouring under the com- 
plaint ; yet fome difference, I think, ought to 
be made in our manner of treating a patient 
who is feized with this difeafe in the full vigour 
of life, paid one debilitated by previous illnefs, 
or of a very feeble conftitution. 

The principal means advifed previoufly to 
the operation are, bleeding, purgative medi- 
cines, purging clyfters, opiates, the warm- 
bath, the cold-bath, the application of cloths 
dipped in cold water, folutions of crude fal 
ammoniac, ice, ether evaporated on the part, 
and the injection of tobacco in fume or de- 
coction ; to which mull be added the attempts 

to 



122 Strangulated Hernia. 

to replace the ftranguiated part lira pofture 
favourable to reduction. Authors have wen 
us inftances of the fuccefs of all thefe means, 
I have feen each of them fucceed. I have 
feen them all fail. I have feen the ftransru- 

o 

lated parts retire without the ufe of any 
means, and even after the ftrangulation had 
continued many days. The recital, therefore, 
of -Angle cafes, in which fuccefs was obtained 
by this or that method (though not ufelefs), 
does not much advance our knowledge. We 
want to know the comparative merit of each 
method, and this it is difficult to obtain. I 
will give the refult of my .experience on each 
of thefe methods. 

Bleeding, The flranguiated hernia has 
been ufually confidered, till of late, as .an in- 
flammatory difeafe, and the ufe of the lancet 
has been almoft univerfally adopted. Mr. 
Pott, who wrote much from his own expe- 
rience, fays, " Perhaps there is no difeafe af- 
" fefting the human body in which bleeding 
" is found more eminently and immediately 
" ferviceable than in this, and which, there- 
" fore, if there are no particular circumflances 
" in the conftitution prohibiting it, ought 
" never to be omitted/' Pott's works, 'vol, 
ii. p.. 68, octavo edition, 



Strangulated Hernia. 123 

Mr. Benjamin Bell gives the fame advice. 
" Blood letting is here a principal remedy. 
" In no difeafe is it either more indicated 
" from appearances, or affords more relief in 
" reality." Surgery, vol. i. p. 275. 

On the contrary, Mr. Wilmer of Coventry, 
who has publifhed fome valuable obfervations 
on ftrangulated hernia, is of opinion, that " in 
" thefe cafes, the death of the patient can 
" only be explained by the inverted periftaltic 
'• motion immediately leffening the powers of 
" life," and thinks " that large and repeated 
** bleedings muft increafe the debility, and 
" do much mifchief." Obf. on Hernia, p. 
39. He thinks that bleeding " is extremely 
" unfavourable to the patient's recovery," 
fhould the operation for reducing the hernia 
be afterwards performed ; and after declaring 
that " ffioft of the patients who are brought 
'* into public hofpitals die after this operation," 
he ieems to attribute this want of fuccefs to 
their having been bled copioufly. lb. p. 45. 

Mr. Alanfon of Liverpool coincides with 
Mr. Wilmer in his opinion of the inutility of 
bleeding in this difeafe. He tells us, that 
bleeding ad deliquium had been the conftant 
practice at Liverpool, and adds, " As foon as 
c -' the deliquium happened, the taxis was tried 

" during 



124 Strangulated He&kia. 

u during that ftage ; but I never faw this me- 
" thod fuccefsful, nor do. I think bleeding 
" ever of the fmalleft fervice in forwarding 
46 reduction." lb. p. 44. 

Amidft this contrariety of opinions, what 
path muft the young practitioner purfue ? I 
entertain a favourable idea of all thefe au- 
thors ; yet it is impoffible that I mould think 
them all to be right in thefe difcordant fen- 
timents. If I may be allowed to judge from 
my own experience, I muft conclude, that 
this matter has been carried to an extreme 
on both fides. I have feen fome cafes in 
which bleeding lias been clearly ufeful. I 
have feen others in which I judged it to be 
highly improper. I will relate an inftance or 
two on both fides the queftion, from, which 
the reader may better comprehend my mean- 
ing. ' 

V A b Jj JL 

Nov. 24th, 1766. I vifited, in the even- 
ing, William Pratt of Eramley, a ftout young 
man, whom 1 found labouring under a ftran- 
gulated hernia. The flrangulation had fub- 
fifted about feven hours, during which time 
he had drunk about half a pint of gin, diluted 

with 



Strangulated Hernia. 125 

with water, apprehending his complaint to be 
the colic. He vomited frequently, and had a 
full, ftrong, and frequent pulfe. He could 
fcarcely fuffer me to handle the tumour, 
though there was no external appearance of 
inflammation. There was no tenfion of the 
abdomen. I onened a vein in each arm, and 
took away, in a fpeedy manner, betwixt twenty 
and twenty-four ounces of blood, while he fat 
upright in bed. He felt himfelf immediately 
relieved ; and when I examined the groin, 
after tying up his arms, the hernia had retired. 

CA.SE II, 

Nov. 13th, 1775. William Renton, porter 
to the General Infirmary at Leeds, arofe 
about two in the morning, to affift the chimney- 
fweepers ; but became fo ill v/ith pain at his 
ftomach, and ficknefs, that he was obliged to 
go to bed again at five. He continued all 
day to complain of much uneafinefs at his 
ftomach, and vomited up every thing that he 
took. I happened to be at the Infirmary in 
the evening-, and viiited him. The late Dr. 
Crowther had prefcribed for him a folution of 
Epfom fait, but it was conftantly rejected. 

Knowing 



1:26 Strangulated Hernia. 

Knowing that he was fubjefit to a hernia, I 
inquired if it was now prokpfed. He feemed 
at firft not to have thought about it; but 
upon my examination, he acknowledged that 
it had been down all the day, though he had 
no pain in the tumour* I ordered him to lit 
up in bed, while about a pint of blood was 
drawn by opening a vein in each arm at the 
fame time. He became fick before the eva- 
cuation was finifhed, but had no cleiiquium. 
Immediately after the bleeding' I placed him 
in a horizontal pofition, and tried to reduce the 
inteftine, which now went up very readily, 
though I had before the bleeding attempted 
the reduclion in vain. 

I relate thefe cafes to' (hew, that there are 
circumftances in which bleeding may be of 
ufe ; but I do not mean to imprefs upon the 
reader an idea, that a like happy termination 
will generally attend this evacuation. I know 
it will not. My own experience leads me to 
concur fo far with Mr. Wilmer and Mr. Alan- 
fon, as to declare, that bleeding has generally 
failed to procure a reduction of the ftrangu- 
lated inteftine, though I am perfuaded that in 
many cafes it may be ufed with advantage. I 
cannot, however, agree with Mr. Wilmer in 
thinking, that it generally renders the fubfe- 

quent 



Strangulated Hernia. \a7 
quent operation more dangerous. The follow- 
ing obfervations induce me to differ from this 
opinion. 

When the operation . proves unfuccefsful, 
without gangrene of the prolapfed part, the 
patient almoft always dies with fymptoms of 
the ileus ; and this difeafe (which is an inflam- 
matory affection of thfrnnteftines) generally 
fucceeds the operation in fome degree, if the 
patient recovers with difficulty. Though I 
confider proper purgatives as of greater 
efficacy than bleeding in the cure of this dif- 
eafe; yet I cannot fuppofe that it is ever 
brought on by previous bleeding. 

Again, in all the cafes which I havq, fe^en, 
where the operation has not fucceeded, and 
where I have had an opportunity of examin- 
ing the body after death, I have found figns of 
inflammation in the mteftmes, or omentum, or 
both. I have found inflammatory, and even 
gangrenous affeftions, at a confiderable dis- 
tance from the part which had been prolapfed. 
"W arner and Le Dran have obferved the fame 
appearances. The former, in differing the 
body of a patient who died on the 20th day 
after the operation, found " the inteftines in 
" general greatly inflamed, the ileum morti- 
** fied in many places 3 and feveral abfeefTes 

" formed 



128 Strangulated Hernia. 

" formed in the mefentery " Cafes in Surgery ^ 
ed. 3, p. 197. The latter fays, " I have often 
" feen this whole canal inflamed, and marked 
" in feveral places with gangrenous fpots." 
Gatakers Tranjlation of Le Draris Opera- 
rations, p. 80. 

Purgative Medicines. My experience- leads 
me to condemn aim-oft univerfally the ufe of 
purgatives taken by the mouth, while an 
inteftine remains firmly ftrangulated. In the 
enter o-epiplocele, when the inteftine has- re- 
tired, and the omentum remains ftrangulated ; 
or in a (mi pie ftr angulation of the omentum, 
where the inteftine has not been prolapfed, 
purgatives are of great utility. So likewife in 
very large and old hernias, where there is rea- 
fon to doubt whether the difeafe is not to be 
conlidered as a morbid affection of the intef- 
tinal canal, rather than the effect of ftrangu- 
lation, purgatives may be as ufeful as in the 
fimple ileus without hernia. While the intef- 
tine remains firmly ftrangulated, they ufually 
increafe the vomiting, and add to the diftrefs 
of the patient. If they are to be tried at any 
time with hope of fuccefs, the trial w T ould ap- 
pear to have the greateft advantage when the 
vomiting has been removed by means of an 
opiate ; yet I have repeatedly given them in 
<jr> vain 



Strangulated Hernia. 129 

vain during fuch an interval of relief. I once 
had an opportunity of trying their effect under 
the moft favourable circumftances, while the 
ftrangulation remained unabated. 

CASE III. 

John Handley, aged forty-five years, who 
had a fmall irreducible Epiplocele, by making 
fome confiderable exertions in lifting a table, 
caufed a fudden increafe of the tumour, which 
was followed by the ufual fymptoms of ftran- 
gulation. His pulfe was betwixt feventy and 
eighty. He was directed to take immediately 
a dofe of ol. ricini, and afterwards to take 
magnef. alb. 3 fs every two hours, drinking a 
table fpoonful of lemon juice after each dofe. 
Cloths dipped in cold water were applied to 
the tumour. Thefe means afforded no relief. 
Neither of the medicines wquld reft upon his 
ftomach. On the fecond day of the ftrangu- 
lation he was put twice into a warm bath, and 
had two clyfters injected, made with a decoc- 
tion of a drachm of tobacco boiled in a pint 
pf water for ten minutes. Both the clyfters 
caufed great ficknefs, but did not produce a 
return of the hernia. At bed time he took 
fifty drops of cinct opii. 

K The 



130 Strangulated Hernia. 

The opiate procured a comfortable nighty 
and the vomiting 'ceafed for forty-eight hours, 
during which time he took nine table fpoon- 

f ills of caftor oil, and half a. drachm of the 
extract coioc. cornp., all which .medicines were 
retained upon his ftomach. Purging clyfters 
were alfo frequently injected during this inter-. 
val of two days, and the ufe of the warm bath 
was repeated. 

At the end of the fourth day, from the 
commencement of the ftrangulation, the vo- 
miting; returned, and continued all the nipiit. 
I was called to vifit him at fix in the morninp*. 
and found him vomiting freauently, having; 
the hiccough, with tenfion of the abdomen, 
which had not fubfifled before. His pulfe 
was now frnall and frequent. 

I "immediately performed the operation, and 
found a portion of omentum in the hernial 
fac, inveloping a fmall portion of interline, 
which was of a dark brown colour. The her- 
nia was of the femoral kind. It was with 
great difficulty that I could introduce the tip 
of my fore-finger within the neck of the her- 
nial fac, fo as to enable me to divide the part, 
which caufed the ftri£ture, % with fafety. Part 
of the omentum adhered to the hernial fac, 

# This part will be defcribed hereafter. 

which 



Strangulated Hernia. 131 

which was thickened where the adhefion took 
place. I cut off the difeafed part of the fac, 
with the omentum adhering to it. Such part 
of the omentum as appeared to be quite found 
was reduced ; but the greater part of it was 
left in the wound. A fmall plug of lint was 
introduced into the orifice. 

No medicine was given to him, as fo much 
of the caftor oil had ftaid with him. He had 
fix copious ftools, and three fmaller ones in 
the courie of the firft twenty-four hours. He 
found great relief from the operation. In the 
evening he was perfectly eafy, and told me, 
that he had had a rare day. The fmall plug of 
lint came away, and the difeafed part of the 
omentum was caft off, on the feventh day after 
the operation. He recovered very well. 

Purgative Clyjiers. I cannot fay that I 
have feen one cafe in which clvfters, either 
made with purgative ingredients, or fimply 
laxative, as of broth, or water gruel with oil, 
have produced a return of a ftrangulated 
hernia. Such injections will empty the larger 
inteftines ; but they have feemed to me to do 
no more. It is common for a natural evacu- 
ation to be the immediate confequence of 
^angulation. 

x 2 Warm 



132' Strangulated Hernia. 

Warm Bath. Many inftances , are upoa 
record of the good effect of warm bathing in 
procuring the reduction of a ftrangulated 
hernia. I have often feen it ufeful ; but I have 
alfo often feen it fail of fuccefs. Whenever it 
is ufed in this difeafe, the patient mould be 
placed, if poffible, in a horizontal pofition. 
Gentle efforts with the hand to reduce the 
prolapfed part are perhaps attended with lefs 
danger, and with greater profpect of fuccefs, 
while the patient lies in the Bath, than in any 
other poiition. The free ufe of opiates coin- 
cides with that of warm bathing, and, under 
fome cireumftances, thefe means deferve to 
be. tried in conjunction, as was clone in the 
following cafe, 

C A S E IV, 

February 2d, 1771, I was defired in the 
evening to vifita poor woman, who lived about 
a mde from Leeds, on account of a vomiting, 
which had afflicted her all the day, attended 
with violent pain in the abdomen. Upon 
examination I found that fne had a ftran<m- 
lated femoral hernia. Her pulfe was not very 
frequent, The abdomen was painful when 

comprcffedj 



Strangulated. Hernia. lib 

comprefled, but was not much inflated. She 
informed me, that flue had been fubject to the 
rupture for feveral years, which had been re^ 
peatedly ftrangulated for a fhort time. She 
was now violently affected with the cramp. 
Her fingers were almoft continually rigid. 
She had pain in the abdomen, which feemed 
to arife from fpafm, and not from the hernia; 
for it feized her by paroxyfms, during which 
fhe cried out, and could not bear to lie upon 
her back. In fhort, almoft all the external 
mufcles, except thofe of the face, were affected 
with fpafm. There was reafon to believe that 
this diforder arofe from inanition, as fhe had 
given fuck to a child for two years, and pro* 
bably had not always enjoyed a plentiful 
table. She had of late been often troubled 
with the cramp* 

. Under thefe circumfiances I thought that 
opium and the warm bath would afford the 
mod fuitable means for promoting the return 
of the hernia. I ordered a warm bath to be 
prepared immediately, and directed four 
draughts, one containing tinct. thebaic, g" xx* 
and the other three g" xv. each : of thefe fhe 
was to take one every two hours* But previoufly 
to the ufe of thefe means a purging clyfter was 
injected? as fhe had had, no evacuation in the 

K 3 courfe 



134 Stean-gulated Hernia. 

courfe of the day. She took the draught, 
with t. theb. g u xx. as foon- as fhe came out o£ 
the bath, but could not retain it upon her 
ftomach ; at leaft, fhe had retchings after 
taking it. The other draughts were not re- 
jected ; fhe became compofed, the vomiting 
ceafed, and in the courfe of the night the her* 
nia retired. 

Opiates. I have £een feveral cafes in which 
opiates given freely (in athletic perfons after 
bleeding) have procured a reduction of a 
ftrangulated hernia. I have alfo received 
accounts of fuccefs by the fame means from 
fome of my medical correfpondents; but lean- 
not lay that this remedy is generally fuccefsfuh 
One circumftance relative to the ufe of this 
medicine defer ves to be noted, viz. that it will 
often remove for a time the pain and vomiting, 
ufually attendant upon a flrangulation, even 
where it proves ultimately inefficacious. I have 
already related one inftance in which the vo- 
miting and pain were fufpended during forty- 
eight hours, fo that the patient lay eafy, and 
retained upon his ftomach every thing that he 
took, though the ftrangulation continued, 
I have feen other inftances of perfons remain- 
ing eafy, and free from vomiting, for twenty-* 
four hours, after taking fifty drops of tinftura 
* opih 



Strangulated Hernia. 135 

opii. On this account opium is a valuable 
remedy, when the patient is fo htuated, that it 
is necefiary to remove him to a confiderable 
diftance before the operation can be perform- 
ed. Opiates mould be given in large dofes, 
when it is intended to try their effect' for 
procuring reduction ; and whenever the fymp- 
toms of itrangulation return, after having been 
removed by the ufe of opiates, the operation 
fhould be performed without further delay. 

Cold stupes, and cold bath. Mr. Wilmer 
has recommended the former of thefe means 
fo ftrongly, that they are now frequently, if 
not generally, ufed as the principal remedy for 
procuring reduction. They had been men- 
tioned by former authors * t * and I had directed 
them, before Mr. Wilmer publifhed on the 
fubject. I have ufed them very frequently, 
fometimes with evident advantage, but oftener, 
I am forry to fay, without fuccefs. I have no 
objection to this remedy, as I am not con- 
fcious that I ever faw it do harm ; but rela- 
tions of its fuccefs after a long continued ufe 
fhould be heard with fome caution, as there is 
danger of deferring the operation, through the 
continued ufe of this remedy, till the life of 

* Medical EfTays (of Edinburgh) vol. v. 232. 

K 4 the 



136 Strangulated Hernia* 

the patient mall be loft by the delay. Il 
would be a more valuable remedy, could we 
determine the length of time neceffary for a 
fufficient trial of its efficacy* in any particular 
cafe* that we might on the one hand avoid a 
xieedlefs operation, and on the other* guard 
againft a fatal delay. I once mcceeded in 
procuring reduction by other means, after the 
cold ftupes had been applied during the whole 
night, and a great part of the fucceeding day* 
as I fhall hereafter relate. 

I have feen a fmgle immerfion in cold water 
caufe a fpontaneous afcent of a Itrangulated 
interline ; but this method has alfo failed of 
fuccefs. I have twice tried the darning of cold 
Water upon the abdomen and thighs, while 
the patient ftood uncovered, but without 
fuccefs.' , ; 

InjeSions of Tobacco. This I confider as 
one of the moft efficacious remedies in the 
ftranguiated hernia, previously to the opera- 
tion ; yet truth will not permit me to lay, that 
it is even generally fuccefsful. I have, how- 
ever, feen it fucceed when other means have 
failed, as in the following inftances. 



CASE' 



Strangulated Hernia* 137 

CASE V, 

November 29, 1779, as I was paffing. 
through Rothwell, a village near Leeds, I was 
defired by a poor woman to viiit her fon, a boy 
of thirteen years, who had lain about forty-* 
eight hours ill with a ftrangulated fcrotal her- 
nia. He vomited every thing which he drank, 
and had much pain in the belly, which, how- 
ever, Was not greatly inflated. His puife was 
at ninety-four, and rather tenfe. The tumour; 
would not bear handling without exciting 
much pain; but the integuments retained theii* 
natural colour. I placed him in aft upright 
pofture, while I took about fix ounces of blood 
from him ; and that the evacuation might be 
the more fpeedy, I opened a vein in each arm. 
He compla ned of licknefs 9 but did not faint. 
The hernia ftill remaining^ I fufpended him 
by the lower extremities over the fhoulders of 
an affiftant, and attemuted the reduction in 
this polition, applying to the tumour at the 
fame time cloths dipped in cold water. This 
method alfo failed of faccefs. I then placed 
him in bed, 'and continued the application of 
the cold wet cloths till the lower part of the 
tumour felt cold. The hernia was not reduced 
by any of thefe means. I then injected a 

clvfter 



138 Strangulated Hernia. 

clyfter, made by boiling for a (hort time half 
a quarter of an ounce of tobacco in half a 
pint of water. The clyfter had not been 
Inje6ted ten minutes before the boy began to 
complain of being very fick, and had fome 
retching. I now attempted again to reduce 
the hernia, and fucceeded with great eafe. 

CASE VI. 

In the fummer 1782, Samuel Edge, aged 
forty years, was admitted an in-patient of the 
General Infirmary at Leeds, on account of an 
afcites and univerfal anafarca. He had been 
afflifiied with an afthma many years, but the 
dropfy had not come on till the preceding 
winter. Firft one, and then the other, of his 
legs began to fwell. Afterwards his abdomen 
became enlarged. In the abfence of his phy- 
fician I directed him to take three grains of 
powdered fquill, mixed with a little pulv. e 
tragac. c, three or four times a day, as his 
ftomach would bear it. The medicine agreed 
with him, and the dofe was increafed till he 
took eight grains of the fquill five or fix times 
a day. He continued to take it in this dofe 
about fixteen days, excepting two, on which 
the dofe was diminifhed on account of 
its proving too laxative. The diuretic effe6l 

was 



Strangulated Hernia. 13$ 

Was considerable, and both the afcites and 
anafarca were completely removed* 

This poor man was fubject to a hernia, 
which by his cough was rendered very trou- 
blefome. Before he was difmiffed from the 
Infirmary, the hernia became ftrangulated, in 
which ftate it had been two days, before I was 
informed of the complaint. He complained 
of pain in the abdomen, and had a vomiting. 
The houfe apothecary* not being informed, as 
I mould fuppofe, of the hernia, had given him 
a gentle emetic, and afterwards a laxative 
medicine. As he had had fome evacuation by 
flool on the day on which I firft faw him* 
though the hernia could not be reduced by 
gentle preffure, I only directed an opiate, 
imall dofes of cathartic fait, and the applica- 
tion of cold water to the tumour. 

The next day I found him worfe. The ca- 
thartic fait had been rejected. He had taken 
three grains of opium, and had applied cloths 
dipped in cold water during the whole of the 
night, and part of two days,, Though a large 
evacuation of blood was undoubtedly forbid- 
den by the previous weaknefs of this patient, 
yet I ventured to take about fix ounces from 
his arm*, and then inje&ed aclyfterofthe 

* In a fimilar cafe, I (hould now omit the bleeding. 

decoction 



140 Strangulate!) H^MiAa 

decofition of tobacco, made by boiling n 
drachm of the cut leaves for. ten minutes in a 
pint of water *. 'Within fifteen minutes after 
this clyfter was given^ he informed me that he 
felt a J udden degree of eafe in his belly, I 
immediately attempted to reduce the inteftine * 
and it receded with eafe. 

A trufs was immediately applied, and the 
man had no more complaint. 

I have frequently injecled the fume of to-* 
bacco in the ftrangulated hernia , but am in^ 
clined to prefer the decoction. I wi(h I could 
fay, that this has not often failed, like every 
other means which I have tried. I think, 
however^ I may venture to fay, that no 
method has fucceeded fo often; and that I 
have fcarcely ever feen any other remedy 
fucceed, without the operation, when this had 
failed of procuring an evident diminution, at 
leaft, of the tumour. One thing muft be 
allowed in favour of this remedy, that it dis- 
covers in a fhorter time than any other, whe- 
ther there is a probability of obtaining a re- 
duction of the hernia without the operation, 
I have ufually thought one trial of this remedy 

* Wherever a clvfter of the decoction of tobacco is 
mentioned in thefe obfervations, it muft be underftoodto 
be made after this formula; nolefs otherwife fpecified. 

to 



Strangulated Hernia. 141 

to be fuffieient ; but have fearcely ever directed 
more than one repetition. When this has 
failed of fuccefs, the operation has difcovered 
fuch a ftate of the ftrangulated parts, as to 
fatisfy me, that no hope of advantage remained 
from a longer delay. 

I have taken no notice of poultices, or par- 
tial warm fomentations. The efficacy of thefe 
means feems almoft univerfally to be doubted, 
if not denied, by thofe who have had much ex- 
perience in the treatment of this complaint. 

The feleQdon of the various remedies above- 
mentioned muftbe left to the judgment of the 
practitioner, who ffiould be guided, in fome 
tneafure, by the different circumftances of 
each cafe. But I can fearcely prefs in too 
ftrong terms the neceffity of an early recourfe 
to the operation, as the moft effectual method 
of preferring life in this dangerous difeafe. 
If Mr. Pott's opinion be true, that the opera- 
tion, when performed in a proper manner, 
and in due time, does not prove the caufe of 
death oftener than perhaps once in, fifty tirnes ; 
it would undoubtecLpreferve the lives of many €te 
to perform it almoft as foon as the difeafe 
commenced, without increafmg the danger by 
fpending much time in the ufe of means a 
which cannot be depended upon for a cure, 

I hare 



'142 Strangulated Hernia. 

I have twice feen this difeafe prove fatal in 
about twenty -four hours'*". In fuch. cafes it 
is evident there is little time for delay. A fur^ 
geon, who is competent to perform the. opera-? 
tioii, is not perhaps confulted till the inteftine. 
is on the point of being mortified, or is actu- 
ally in a ftate of mortification. The dilemma 
into which he is then caft is painful- indeed. 
But when the fuller! opportunity is afforded 
him of ufing the heft mode of treatment, I am 
fatisfied that his fuccefs will be the greateft 
when the operation is not long delayed. This, 
at leaflyhas been my own experience. When 
J firft entered upon the profeffion of furgery. 
In the year 1759 3 the operation for the ftran* 

# In one of thefe cafes I made ufe of no means, as I 
did not fee the patient till about half an hour before his 
death. In the other cafe, the patient, though a young 
xp f an, died immediately after the operation. But this, 
was a complicated cafe. On the preceding day the her- 
nia had received a blow from a (hovel, which produced 
the ilraugulation, and an inflamed itate of the parts. 
His pulfe was very frequent. Twelve ounces of blood 
were, taken from his arm. A Tobacco-clyfter was in 
jecled ; and cold flupes were applied to the tumour, 
'which was in a very tenie" ftate.; But he funk rapidly. 
He was reitlcfs., and rather delirious during the opera- 
tion, which was performed as the only means which 
then afforded the Jeaft hope of preferring his life ; but 
|je expired., as ibo'ii as it was iinifhccl., in the acl of 
vomi ting» 

gulated 



Strangulated Hernia. 143 

gulated hernia had not been performed by 
any of the liirgeons in Leeds. My feniors in 
the profeffion were very kind in affording me 
their affiftance, or calling me into confutation 
when Inch cafes occurred ; but we confidered 
the operation as the laft refource, and as im- 
proper until the danger appeared imminent. 
By this dilatory mode of practice I loft three 
patients in five upon whom the operation was 
performed. Having more experience of the 
urgency of the difeafe, I made it my cuftom, 
when called to a patient who had laboured two 
or three days under the difeafe, to wait only 
about two hours, that I might try the effect of 
bleeding (if this evacuation was not forbidden 
by fome peculiar circumftances of the cafe) 
and the tobacco clyfter. In this mode of 
practice I loft about two patients in nine upon 
whom I operated. This comparifon is drawn 
from cafes nearly fimilar, leaving out of the 
account thofe cafes in which a gangrene of the 
inteftine had taken place, 

I have now, at the time of writing this, per- 
formed the operation thirty-five times*; and 
have often had occafion to lament that I had 

# Since the beginning of the year 1794, my fon, who 
is now my partner in bufinefs, has generally performed 
the operation in my private practice. Thefe cafes are 
pot reckoned in the number here fpecified. 

performed 



144 Strangulated Hernia 

performed it too late, but never that I had 
performed it too foon. There are fome cafes fo 
urgent, that it is not advifeable to lofe any 
time in the trial 1 of means to produce a reduc- 
tion. The delay of a few hours may cut off 
all hope of fuccefs, when a fpeedy operation 
might have faved the life of the patient-*. 

I am perfuaded, that much harm has been 
done by long continued efforts to replace the 
ftrangulated inteltine. The patient, who has 
"been accuftomed to reduce his own hernia, will 
perform the operation of' the taxis with the 
greater! faiety. If he fails, the furgeon mould 
be cautious of doing much. Sufpenfion oveF 
the (boulders of an affiftant or two has been 
thought to favour the reduction confiderably. 
I have tried it often; but have not found it 
to be of fuch fuperior efficacy as fome authors 
have reprefented. When the ftrangulati.cn 
ceafes, the Hernia often retires fpontaneouily, 
pr with the (lighted efforts, if the patient is 
in a horizontal polition, 

* However urgent be tbe cafe., I fhould riot advife the 
operation to be performed during the ficknefs and lan- 
guor which u finally follow the injection of a decoction 
of tobacco. The operator ought, in my opinion, to 
wait till the patient is free from the debilitating effects 

of that remcdv, 

■< » ■ 

In 



Strangulated Hernia. 145 



In defcribing the operation for the firangu- 
lated hernia, I fhall omit thofe directions 
which are mentioned by almoft all writers 
on the operations of furgery, and confine my 
remarks to thofe, which either have not been 
mentioned, or which deferve a particular at- 
tention. 

In the fcrotal hernia the inciCon ought to 
begin a little above the abdominal ring, 
otherwife the furgeon will be under the necef- 
fity of enlarging the incifion, or will be hin- 
dered by the integuments when he attempts 
to divide the ring. 

The incifion ought to be continued through 
the fcrotum as far as the loweft part of the 
hernial fac. For fince the veffels and nerves, 
which conftitute the fpermatic chord, are 
fometimes fo far difplaced and feparated by 
the hernia, that one, or more of them, have 
been found lying upon the anterior part of the 
fac ; they can neither be difcovered, nor 
avoided, unlefs the fcrotum be divided pre- 
viouily to the divillon of the hernial fac. Le 
Dran fays, " I have feen, though but once 
* only, the fpermatic chord fituated ante- 

L " riorly 



146 Strangulated Hernia, 

" riorly upon the hernial fac/'* I have 
twice feen the vas deferens lying upon the 
anterior furface of the hernial fac. In one 
patient, an old man betwixt fixty and feventv? 
it lay before the lower part of the fac only ; 
and when I had fmifhed the operation, I found 
that I had divided it, by making the incifion 
through the lower part of the fcrotum and 
hernial fac at the fame time ; which I had done 
to avoid giving the pain of two incifions. 
Since that time, I have always divided the 
fcrotum intirely before I cut through the 
fac. 

The opening of the hernial fac mould be 
made with great caution. There is fome- 
times, indeed, fuch a quantity of fluid in the 
fac, that no harm would enfue from an un- 
guarded perpendicular incifion ; but I have 
often feen the inteftine and omentum in con- 
tact with the fac, fo as to render fuch an inci- 
fion dangerous. The beft method is, to dif- 
fe6t very cautioufly the moft prominent part 
of the hernial fac, for about an inch in length, 
dividing the layers of aponeurotic fubftance* 
if there are any, with the intervention of a 

, * Gataker's Tranflation of Le Dran's Operations, 
p. 95, 

imall 



Strangulated Hernia, 147 

fmall director ; and then to cut the remaining 
part of the hernial fac with the edge of the 
knife turned horizontally, having elevated 
what you are about to cut with the differing 
forceps* By this method the fac may always 
be opened without danger. 

As foon as the fac is opened, which is 
ufually indicated by the iffuing of a thin fluid, 
and the orifice is fufticiently enlarged to ad- 
mit the finger, the remainder of the fac may 
be divided by the curved bubonocele knife* 
But I would advife the operator to avoid 
carrying his incifion quite to the inferior ex- 
tremity of the fac, in the fcrotal hernia. This 
is fo connected with the tunica vaginalis, that 
the latter is in danger of being divided, if the 
incifion is carried on to the extremity of the 
fac. I have ieen this happen, and therefore 
commonly leave a quarter or half an inch of 
the fac undivided 9 which practice I never faw 
attended with any inconvenience. 

The next ftep is to enlarge the aperture 
through which the prolapfed parts have de- 
fcended from the abdomen, by dividing the 
aponeurofis of the external oblique mufcle, to- 
gether with the neck of the hernial fac, which 
fometimes produces the principal part of the 
ftriclure. If the tin of the fore-finder can be 

L % fufficiently 



148 Strangulated Hernia. 

fufficiently introduced to conduct the bubo- 
nocele knife s the divifion may be made in this 
way with the greateft advantage. It fhould 
be made upwards and a little outwards, when 
the hernia defcends through the abdominal 
ring ; and in this fpecies of hernia I have never 
found any difficulty in executing this part of 
the operation, 

The divifion of the femoral ring (if I may 
be allowed the expreffion) is a matter -of great- 
er importance, and merits a particular difcuf- 
fion. In the male'fubjefit both the epigaftric 
artery, and the fpermatic chord, lie fo near the 
aponeurotic border of the external oblique 
mufcle of the abdomen, palled Poupart's liga- 
ment, that there is great danger of wounding 
the one or the other of thefe, if that ligament 
is divided in this operation. In females, the 
epigaftric artery alone requires our attention. 

To avoid the danger arifing from a divifion 
of that ligament, Mr. Benjamin Bell has in- 
vented a new method of operating in the fe- 
moral hernia, which he has defcribed at large 
in his Syftem of Surgery, vol. i. p. 363. I lliall 
not enter upon an examination of this method, 
as I am fatisfied that the ftriclure, in this 
fpecies of hernia, is not caufed by Poupart's 
ligament, but by another part, which I mall 
3 prefently 



k. 



4i 



Strangulated Hernia. 149 

prefently defcribe, the divifion of which may- 
be executed without danger to the fpermatic 
or epigaftric artery. 

Mr. Pott was fo apprehenfive of the dan- 
ger of dividing Poupart's ligament, that, in his 
Treatife on Ruptures, he rather mriiiks from 
the difcufilon ; adviiing the furgeon to reduce 
the prolapfed parts without any divifion, 
which/' he fays, " may almoft always be 
i done, confidering the large fpace between 

the os ilion and the os pubis, and that that 
" fpace is occupied principally by cellular 
" membrane and fat/'* In his Section on the 
Femoral Hernia, he repeatedly takes notice of 
this " confiderable fpace between the os ilium 
" and the os pubis," mentioning it not only 
as the reafon why a ftrangulated hernia. may 
be " returned without dividing the tendon/' 
but alfo as accounting for the lefs frequent 
ftrangulation of the femoral hernia, Thefe 
declarations furprife me exceedingly, coming 
from the pen of an author, who wrote fo much 
from his own experience, as I apprehend Mr. 
Pott to have done. If we look at the ikele- 
ton, we fhall undoubtedly fee a confiderable 
fpace between the os ilium and the os pubis ; 
but if we take our ideas from a fubjecl labour- 

* Pott's Works, octavo ed. vol. ii. p, 138. 



L 3 mg 



150 Strangulated Hernia. 

ing under a ftrangulated femoral hernia, we 
fhall rather wonder, from the fmallnefs of tha 
aperture, how a defcent could have happened, 
I have now performed the operation for the 
femoral hernia fourteen times in the female,* 
and twice in the male fubjefit, and have al- 
ways found great difficulty in introducing the 
fmalleft portion of my fore-finger into the fe^ 
moral ring, for the purpofe of conducting the 
bubonocele knife. Nay, this introduction I 
have twice found impracticable, and have been 
under the neceffity of making ufe of a direct 
tor. In no cafe in which I have operated, did 
there appear the leaft probability of reducing 
the prolapfed parts without previoufly enlarge 
ing the aperture. 

Don Antonio de Gimbernat, furgeon to the 
King of Spain, is the only author with wfaofe 
works I am acquainted, who has afferted, that 
the ftrangulation in the femoral hernia is not 
caufed by Poupart's ligament. He informs us*, 
that he firft demonftrated this in ] 76& 3 and 
afterwards in 1777 explained the fubjefit to 
the late Dr. Hunter, by means of an anato-* 
mical preparation. His treatife induced me 
to examine repeatedly the parts concerned in 

* In his New Method of operating for the Femoral 
ilernia, translated \>y Dr. Beddoes, p. 30, 

the 



Strangulated He&nia. T5i 

the formation of the femoral hernia, and to 
procure drawings of the parts which I had dif- 
ie&ed. The moft inftruclive of thefe draw- 
ings, which was made by Mr. RufTell, Men> 
ber of the Royal Academy, is here prefented 
to the reader, engraved in a reduced form, in 
the annexed Plate. 

In the femoral hernia the prolapfed parts 
defcend within the aponeurotic (heath, which 
envelopes the great veffels of the thigh, and 
which is ftrongly attached at its fuperior part 
to the offa pubis. The anterior layer of this 
iheath is formed, in part, by a continuation of 
the fafcia of the abdominal mufcles, paffing 
down upon the thigh. About three-eighths 
of an inch below Pouparts ligament, there ex- 
ifts in 'this aponeurotic fheath another* liga- 
ment, fomewhat (imilar to that of Poupart, 
but fmaller. It runs tranfverfely, but does 
not defcend obliquely, as that ligament does. 
On the contrary, it rather afcends as it ap- 
proaches the fymphylis of the offa pubis, paf- 
fing behind, and decuffating, the extremity of 
Poupart's ligament. As I ihall have occafion 
to mention this ligament frequently, I mall, 
by way of diftinftion, call it the femoral liga- 
ment. 

L 4 This 



Ill St&angulatbd Hernia.' 

. This ligament is not fituated. in the fame 
plane with that of Po apart, bat lies deeper, 
that is, at a greater diftance from the integu- 
ments, though it is reprefented in the plate as 
nearly in the fame plane, from being pumed 
Outwards ]py a finger thruft down behind it, 
while the drawing was taken, that it might b§ 
brought more diftinclly into view. 



Defcription of the Plate. 

a. The aponeurosis covering the inferior part 
of the external oblique mufcle of the abdo- 
men, 

b.. Poupart's (or the abdominal) ligament, 
c. The fafcia of the thigh cut off at 
d d, to fhew the great veflels injecled with 
wax. 

e. The femoral vein. 

f. The femoral artery. 

g. The vena faphsena, not filled with in- 
jection, except at its upper part, where it en- 
ters the femoral vein. 

h. A fmall portion of the aponeurotic (heath 
of the great veflels, left when the anterior part 
was removed along with the fafcia of the 
thigh, 

:i The 



Tr fiiee Jk'/t 232. 



FL.4. 




To flirt Pope 152. 



PL. 5 




Strangulated Hernia. i53 

i. The peritoneum thruft down below the 
femoral ligament, by a finger introduced from 
within the abdomen, to give fome reprefenta- 
tion of the femoral hernia. 

k. The femoral ligament , formed in the 
fafcia of the thigh or anterior layer of the 
aponeurotic (heath of the great femoral veffels. 

L The fpermatic chord. 

m. The pe6tinseus mufcle. 

n. The adduftor longus femoris. 

The fafcia of thefe two mufcles was diffect- 
ed off to mew the courfe of their fibres. It is 
thin, and is not a continuation of that fafcia 
which unites with the aponeurotic fheath of 
the great veffels. This fheath lies upon the 
outer edge of the peftinaeus mufcle, and is 
connected with it merely by cellular mem- 
brane ; fo that a finger may be pufhed with 
eafe between the iheath and that mufcle. 

That part of the fafcia of the thigh, to 
which I have given the name of femoral liga~ 
mejit, may eafily be clifcovered, by introducing 
the finger, (after the abdomen has been laid 
open) into the aponeurotic fheath of the great 
femoral veffels, behind Poupart's ligament. 
As the finger paffes downwards, it will be 
preffed upon by a part of the fafcia, more 

compact 



1,54 Strangulated Hernia, 

compact than the reft, which runs tranfverfely 
about three-eighths of an inch below Poupart's 
ligament, and fometimes prefents a {harp edge 
to the finger. When this is examined by dif- 
feclion, it v/ill be found to referable the infe- 
rior border of the aponeurofis of the external 
oblique mufcle of the abdomen. In th^fe^ 
fubje6ts, which I have diffected on purpofe, 
I have not found it equally diftinct; but it 
has been, in all of them* fufficiently apparent. 
In this examination one may perceive, that a 
prolapfed inteftiiie would receive very little 
preffure from Poupart's ligament, in compa- 
rifon of that which it niuft fuffer from this 
inferior ligament, the ftru6ture and fituation 
of which account clearly for the peculiar 
phenomena of the femoral hernia. 

The femoral hernia is ufually of a rounder 
form, and lefs bulk when ftrangulated, than 
the fcrotal hernia. I have repeatedly feen it 
refembling an enlarged inguinal gland. 

It is not fo frequent in males as in females. 
In the latter I have rarely met with a defcent 
of the inteftine through the abdominal ring. 
In all the inftan'ces of ftrangulated inteftinal 
hernia in females which have occurred in my 
practice, the hernia was of the femoral kind, 

in 



Strangulated Hejrnia. 155 

In performing the operation for the ftran- 
gulated femoral hernia, the furgeon ought to 
be aware, that the hernial fae is ufually thin- 
ner than in the fcrctal hernia, After a divi- 
sion of the integuments, the fac ought there-* 
fore to be opened with great caution. The 
ftricture made upon the prolapfed parts is very- 
great, as I have already obferved ; but if the 
tip of the finger can be introduced within the 
femoral ring, to guide the bubonocele knife, a 
fmall incifion (for the ring is narrow) will be 
fufficient to fet the parts at liberty. If the 
tip of the finger cannot be introduced at the 
proper place, a director with a deep groove 
muft be ufed inftead of the finger ; but I pre- 
fer the latter. The finger or director iliould 
not be introduced very near the great veffels ; 
but on that fide of the inteftine or omentum 
which is neareft to the fymprryfis of the ofla 
pubis. The incifion may then be made di* 
reclly upwards. The furgeon muft take efpe- 
cial care to introduce his finger or director 
within that part where he finds the ftri<5ture 
to be the greateft, which, in this fpecies of 
hernia, is the moft interior part of the wound. 
The difficulty of executing this part of the 
operation mould not induce the furgeon to 
divide any part which is of more eafy accefs. 

It 



156 Strangulated Heknia. 

It is much more eafy to divide the abdominal 
(Poupart's) than the femoral ligament ; but 
it is the divifion of the latter only that will fet 
the prolapfed parts at liberty. The aponeu- 
rolls, -which lies between the abdominal and 
femoral ligaments,, is yielding, and will not 
ufually, I believe, prevent the reduction of the 
inteftine, when the femoral ligament is di- 
vided. I had repeatedly wondered, that, in 
this operation, fo fmall a divifion of the moffi 
interior and contracted part mould prove fuf- 
ficient for the reduction. But, iince I have 
difcovered the fituation and ftructure of the 
femoral ring, my wonder has ceafed. I .had, 
from experience, gained a knowledge of the 
proper manner of performing this operation, 
before I had acquired, from anatomical in- 
velligations, a juft idea of the part which 
principally caufes the ftrangulation. I had 
prefumed (as I fuppofe every other furgeon 
did) that I was dividing Poupart's ligament 
when I removed the tincture ; but I knew 
practically, that a fmall divifion of the moft 
interior part ufually proved fufficient. It has 
been my cuftom to take notes of the circiim- 
fiances which occurred in operations for the 
ftrangulated hernia. An extract from fome, 
which I made in 1784, may afford a confir- 
mation 



Strangulated Hernia. 157 

mation of the opinion which I now entertain, 
refpefiting the ftrangulation of the femoral 
hernia, though the obfervation was anatomi- 
cally erroneous. 

I was operating upon a woman, aged fixty- 
ilx, on account of a femoral hernia* which. had 
been itrangulaled three days* The hernia 
s was an entero-epiplocele. " Poupart's liga- 
■" ment," I obferved, " preffed the inteftine 
" clofely, as ufual. After dividing it, fome 
46 of the found inteftine (lipped out of the ab- 
" domen, which I could not reduce. The 
" aponeurofis (forming Poupart's ligament) 
Ci confifted of two layers, which were lepa- 
Ci rated confiderably from each other. When 
" I attempted to reduce the inteftine, it paf- 
fed into the cavity formed between thefe 
layers, and not into the abdomen. I made 
a farther divifion of the internal layer, and 
" the inteftine was then reduced with eafe, 
" and remained in the abdomen/' 

I apprehend that, in this cafe, the fpace 
between the abdominal and femoral ligament 
was rather greater than ufual. I remember 
that the aponeurofis, which lies between and 
connects them, yielded confiderably to my 
preffure. As a portion of inteftine, which 
had not been ftrangulated, defcended upon the 



Liviuon 



158 Strangulated Herria* 

divifion of Poupart's ligament, it fhews$ that 
fome preffure is made upon a femoral hernia, 
by that ligament ; but my inability of redu- 
cing the prolapfed inteftine, without dividing 
another, and interior part, mews, that the 
ftri&ure, caufing the ftrangulation, was made 
by that part, and not by Pouparf s ligament* 
With refpeet to a divifion of the fpermatic 
and epigaftric arteries in this operation, I will 
relate all that has occurred in my own prac- 
tice. No haemorrhage took place in either 
of the operations, which I performed for the 
femoral hernia in males, I may be allowed, 
therefore, to fay that the fpermatic artery was 
not divided in either cafe. The following 
cafe is the only one in which I wounded any 
veffel of confequence, while dividing the part 
which formed the ftri6ture. The accident 
occurred in the early part of my practice, be- 
fore I was aware how fmall an incifion was 
neceffary for removing the ftrangulation in. 
tha femoral hernia. 



CASE VII. 

IN 1764 I was operating upon an old 
woman for a femoral hernia, and attending 

8 chiefly 



Strangulated Herhia. 159 

chiefly to the convenience of introducing the 
tip of my fore-finger, I made the divifion of 
the ring directly upwards, and not on that 
iide of the interline which was rnoft diftant 
from the femoral artery. The incifion was 
alfo longer than I now judge to be necefTary; 
for, in my notes made foon after the opera- 
tion, I ftated, that I judged the incifion 
through the aponeuroiis to have been about 
half an inch in length. The confequence 
■ was, that I opened an artery, which bled 
freely, but of which, neither I, nor the gen- 
tlemen who affified me at the operation, could 
difcover the orifice. Mr. Samuel Sharp fup- 
pofed it to be an eafy matter to take up with 
a needle any veffel which might be wounded 
in this operation ; but this I found to be im- 
practicable. I applied a fmall piece of dry 
fpunge upon that part whence the blood iffued, 
and upon this I placed feveral other pieces, 
till I had raifed them fo high, that the com- 
mon bandage would make a compreffion on 
the bleeding part. During the firft day after 
the operation, an affiftant was directed to keep 
•^m conftant preffure with the hand upon the 
pieces of fpunge. The haemorrhage ceafed by 
this method, and did not return. I began to 
remove the exterior pieces of fpunge after a 

few 



160 -SxRANGtriiATED HbRKIA. 

few days, and gradually infinuated fonie lint 
under that piece which lay in contact with 
the wound. On the 1 4th day after the ope* 
ration, I removed the laft piece of -fpunge. — - 
The wound was cicatrized at the expiration of 
five weeks. 

The third ftage in this operation confifts in 
the difpofal of the prolapfed parts. Here ~fe- 
vera! important considerations prefent them- 
felves, chiefly relating to the management of 
the omentum. 

After unfolding the omentum, in the entero- 
epiplocele, I feparate it from the inteftine, 
and alfo the folds of inteftine from each other, 
if they have contracted an adhefion, by gently 
drawing them afunder. This adhefion I have 
often feen ; but, 1 think, have always been 
able to effect a feparation of the adhering 
parts without the afliftance of any inftrument, 
and without injuring the inteftine, if a gan- 
grene had not taken place*. I always reduce 
the' inteftine, if it is in a found ftate, before 
the reduction of the omentum, which is con- 
trary to the practice recommended by Mr. 
Pott. My reafon for acting thus is an opi- 

* I do not mean to fpeak in this place of an adhefion 
of the omentum to the hernial fac ; in which cafe a re- 
paration can feldombe efFefted without the afliftance of 
the knife, 

nion* 






Strangulated Hernia. 161 

nion, that the interline will bear a protracted 
preffure, without injury, better than the omen- 
tum. When there is a neceffo for cutting off ***j 
a portion of omentum, or feparatingit from the 
hernial fac, or taking up any of its divided 
veffels ; thefe operations may be executed 
with greater fafety after the reduction of the 
interline, 

I once law the coats of the interline {o 
thickened in a fcrotal hernia, that it refembled 
a lump of mufcular fleihj rather than a portion 
of inteitine. I was obliged in this cafe Ifii 
to make a large divifion of the abdominal 
ring before I could effecYthe reduction ; and 
even then the inteitine was not reduced with- 
out difficulty. After feveral ineffectual attempts 
I fucceeded by the following method : I ftood 
with ray right fide to the left of the patient; 
then placing my fingers round the extremity 
of the interline, and directing them upwards 
behind it, I gently pufhed up the higheft part 
of the interline, while the palm of my hand 
fupported the moft depending part. This 
method I have found ufeful in feveral cafes 
where reduction was difficult. 

I muft refer my readers to the works of 
other authors for an account of the treat- 
ment of the interline, when it is found in a 

M gangrenous 



/' 



lJS%8 Strangulated Hernia, 

gangrenous ftate. 1 have feen feveral fucE 
cafes* but the termination of them in general 
was fatal, and I have little to fay upon the 
treatment of them from my own experience.* 
I will relate the particulars of two cafes, 
and will add a conjecture, which may account 
for fome of the recoveries related by authors^ 
in cafes where a prolapfed inteftine was gan- 
grened. 

CASE VIII. 

r In July 1 767, a labouring man, aged thirty- 
eight years, was feized with pain in the fcrotum 
and lower belly, after having exerted himfelf 
in lifting hay with a fork. He did not imme- 
diately examine the fcrotum ; but in the 
morning upon waking, he found the right fide 
of it fwelled, inflamed, and painful, especially 
upon motion. He fent for a furgeon, who 
bled him, gave him laxative medicines, and 
applied a mild poultice to the inflamed part. 

* I have feen but four cafes, in which a patient has 
recovered after a gangrene in a flrangulated hernia. 
Two of the cafes are related in this place ; the third was 
the cafe of Mofes Bradford, related hereafter, where the 
gangrene did not {hew itfelf till the fifth day after the 
operation; the fourth was the cafe of an old lady who 
had a fmall gangrene in an irreducible exomphalos. 

On 



Strangulated Hernia. 1 63 

On the eighteenth clay of the difeafe I was 
defired to vifit him. His bowels had been 
opened by the laxative medicines. He had 
alio taken fome powders with cryftals of tartar 
and nitre, and an opiate at bed time, without 
which he could not fleep. The fcrotum con- 
tinued fwelled, and the inflammation extended 
over the integuments upon the right fide of 
the hypogaftrium. His pulfe was rather 
tenfe, and beat about ninety ftrokes in a mi- 
nute, ladvifed a repetition of the bleeding and 
cooling medicines, with the opiate at bed time. 
On the twentieth day, the tumour was more 
prominent a little below the abdominal ring. 
On the twenty-iirft it burft, and difcharged 
purulent matter mixed with fasces. Several 
orifices were formed in the fcrotum ; and in 
the courfe of a few days, the loweft of them 
became enlarged to about the breadth of a fix- 
pence, by the Houghing of the fcrotum. 
Upon preffing the hypogaftrium, ftercoraceous 
matter, mixed with air, iffued out through the 
fcrotum. Little or no doubt now remained, 
that the tumour of the fcrotum was formed by 
a hernia of the inteftine, which had burft in 
feveral places. This idea was confirmed by the 
fubfequent detachment of a portion of intef- 
tine, about an inch and half in length, and of 

m 2 confiderable 



l64< Strangulated Hernia, 

confiderable firmnefs. Upon wafhing the 
part caft off, I could difcern its villous coat. 
The wound was foon filled with granulated 
flefh, the difcharge of faeces ceafed, and a 
complete cicatrization took place in the courfe 
of two or three weeks, as I was informed; 
for I did not vifit the man after the wound 
was fo far healed as to difcharge no more 
fasces. 

CASE IX, 

September 2 5th, 1801, Caleb Breaks of 
Wibfey, aged forty, was admitted into the 
General Infirmary with a ftrangulated femo- 
ral hernia on the right fide. During the laft 
five or fix years he had been accuftomed to an 
occafional defcent in this part ; but had always 
been able, before this time, to reduce the 
hernia. He perceived the fwelling as he w r as 
w r alking on the 23d inftant, and being unable 
to reduce it as heretofore, and feeling much 
pain in the affefted part, he confulted a fur- 
geon, who ufed confiderable efforts to effe6l 
the reduction. 

Mr. Logan, in my abfence, vifited this pa- 
tient for me at his admiffion, and found the 
hernia in a tender and fomewhat inflamed 

ftate., 



Strangulated Hernia. 165 

ftate. He directed a clyfter to be injected, 
made with the deco6tion of tobacco, and the 
frequent application of cloths dipped in cold 
water. 

I faw the patient at ten in the evening. He 
w r as then under the influence of the tobacco 
clyfter. He complained of iicknefs, had fre- 
quent eructations, and fome degree of cold 
perfpiration. His pulfe, which had been at 
a hundred and twelve at his admifiion, was 
now reduced to fifty-eight. The abdomen 
w r as fomewhat inflated. His tongue was 
white. The inflamed appearance of the hernia 
was, according to my information, rather 
abated. 

As he had rejected nothing which he had 
taken iince the commencement of the ftran- 
gulation, and as he had had an evacuation by 
ftool, there was reafon to think, that the courfe 
of the feces through the inteftinal canal was 
not interrupted. It was judged proper, 
therefore, to try the effect of purgative medi- 
cines for removing the inflation of the 
abdomen and inflamed ftate of the hernia. 
I directed pulv. jalap. 9j. calomel, gr, v. to be 
given, in the form of pills, every three or four 
hours, till three dofes fhould have been taken, 
unlefs a free evacuation Ihould in the mean time 

H 3 take 



\66 Strangulated Hernia. 

take place. A purging clyfter was alfo ordered 
to be injected after the fecond dofe of the 
pills. The application of the cold cloths was 
directed to be continued. 

526th, feven A. M. He had had a copious 
evacuation after the clyfter, and felt himfelf 
much relieved. The inflation of the abdo- 
men had entirely fubfided; but the integu- 
ments appeared inflamed to the diftance of 
two or three inches from the tumour, which 
was round and fmall. I directed the applica- 
tion of a warm poultice of bread and water*, 
inftead of the cold cloths, and the injection 
of another clyfter at noon. Pulfe ninety- 
four. 

Six P. M. The patient had not been, re- 
lieved by the clyfter, which returned without 
faeces. The abdomen was again a little in- 
flated, and the pulfe was at a hundred. I 
ordered ol. ricini % fs. to be riven every four . 
hours till a ftool fhould be procured, 

* The application directed in this cafe may feem in-, 
confident with what I have faid, p. 141, on the inutility 
of poultices in the ftrangulated hernia. But they were 
now . applied to abate the inflammation of the in tegu- 
ments (in a cafe which appeared, at that time, to be a 
mere ftrangulation of the omentum)., and they were 
ufeful for that purpofe. 

a. 



Strangulated Hernia. 167 

27 th, nine A. M. He had had a ftool in 
the evening foon after my laft vifit, and ano- 
ther before ten, on which account he had 
taken only one dofe of the ol. ricini. I found 
him eafy. Pulfe at ninety. Abdomen quite 
flat. Inflammation of the integuments near 
the hernia fubfided. 

He continued to be open in his bowels, and 
the inflation of the abdomen did not return ; 
but after a few days the tumour formed by 
the hernia began to enlarge, and this increafe 
of bulk was attended with fome degree of 
fever. 

06lober 2d. The integuments being now 
rendered thin by the formation of matter in 
the tumour, I divided them in a crucial fornij 
and difcharged a dark coloured, and very 
offenfive matter, mixed with air. There was 
a fmall portion of inteftine in a gangrenous 
ftate, though ftill inflated with air, and fome 
remains of omentum, which had chiefly be- 
come diffolved by putrefaction and fuppura- 
tion. The cavity containing the matter was 
much enlarged, and membranous partitions 
were formed in two or three places. Thefe 
were all divided, and the wound was drefled 
as a common abfcefs. 

M 4 3d. The 



168 Strangulated Hernia. 

3d. The poor man was much relieved by 
the opening made yefterday." His pulfe was 
at eighty-eight. The contents of the cavity 
were yet black ? and extremely fetid. The 
inteftine had become flaccid. A fermenting 
cataplafm was applied for a day or two. 

Some yellow flimy matter appeared now 
and then in the wound, and had the fmell of 
inteftinal faeces ; but there was no other appear- 
ance of faecal matter. 

7th. The mortified part of the inteftine, 
and the fmail remains of omentum, were 
entirely call off, and the furface of the fore 
was covered with good granulations. 

The patient recovered very well, and the 
wound was completely cicatrized without any 
remains of the hernia. 

From all the circumftances of thefe cafes, 
there is little reafon to doubt, that the pro- 
lapfed portion of inteftine was the head of the 
colon. A fimilar cafe is defcribed, and com." 
pletely illuft rated, in the Medical Obfervations 
and Inquiries} vpl. iii. article 8th. The pa- 
tient, who was the fubject of this cafe, had a 
fcrotal hernia on the right fide, which, upon 
being ftrangulated, and neglected, was brought 
into a ftate of gangrene. A portion of intef- 

tine 



Strangulated Hernia. 169 

tine was cut off by the furgeon, who then 
vifited the poor man, and the faeces paffed 
through the wound for fome time. A com- 
plete cure was, however, obtained, and the 
man lived twenty-five years afterwards, with- 
out any return of the hernia. After his death 
the parts were examined, when the caput 
coli and appendicula vermiformis were only 
found wanting. The remaining extremity of 
the colon adhered to the abdominal ring, and 
afforded no obftru6lion to the paffage of the 
faeces. 

Upon comparing thefe cafes, and confidering 
the extreme danger that attends a gangrene of 
any part of the inteftinal canal through which 
the faeces muft pafs, I am induced to conjec- 
ture, that many recoveries, after a gangrene of 
the inteftine, may have been owing to the fame 
caufe which preferred the life of the patients; 
mentioned above. It is remarkable, that 
authors who have related the cafes of patients, 
whofe prolapfed inteftine was gangrened, have 
generally neglected to relate on which fide of 
the body the difeafe fubfifted. My fufpicion 
is not, indeed, confirmed by this neglect ; nei- 
ther is it refuted by it. Future obfervations 
may mew, how far the circumftance I have 

mentioned 



170 Strangulated Hernia. 

mentioned may be confidered as a caufe of 
recovery in hernia with gangrene of the in- 
teftine* 

The proper treatment of the omentum ap- 
pears to me to be one of the moft important 
parts of this operation. If the omentum is 
found, and without adheiion to the hernial 
fac, it ought undoubtedly to be replaced 
within the abdomen ; but the reduction fhould 
be made with the greateft delicacy, as the 
tender texture of the omentum makes it liable 
to be bruifed with very little force ; and 
flight injuries of this part will bring on 
inflammation and gangrene. Too much cau- 
tion cannot be ufed when a large portion of it 
is prolapfed. 

Mr. Pott recommends the reduction of the 
omentum in all cafes. If it adhered to the 
hernial fac, his practice was " either to diffecT: 
" its adhefions, or to retrench a part of it." 
vol. ii. p. 107. If it was gangrened, he 
" always made the excifion in the found part/* 
He adds, that " any portion of the caul, 
" which it may be thought neceffary to re- 
" move, may fafely be cut off/* ib. 118,11 9. 
Notwithftanding this great authority, I have 

always 



Strangulated Hernia. 171 

always been apprehenfive, that wounds of the 
omentum were not fo harmlefs, as they are 
here reprefented to be. My experience has 
not removed thefe apprehenfions. But I will 
lay before the reader the refult of my expe- 
rience, and leave him to determine which 
mode of practice is the moft eligible. 

When the portion of omentum, which is 
prolapfed, is in a found ftate, of little bulk, 
and ftrongly adherent to the hernial fac ; and 
when, from inquiries made of the patient, we 
learn, that this fmall part has been prolapfed 
for many years, without difturbing the func- 
tions of the abdominal vifcera ; we may fairly 
conclude, that we fhall not injure thofe func- 
tions by leaving fuch a portion in its prolapfed 
ftate. In fuch a cafe I have fufFered the 
omentum to remain, and have found no diffi- 
culty in healing the wound, nor any injury 
afterwards from the application of a well 
adapted trufs. In one patient I left a portion 
which I judged to be about two ounces avoir- 
dupois in weight, which w r as the largeft por- 
tion that I have fufFered to remain. The 
wound was healed at the expiration of fix 
w T eeks after the operation. The pad of the 
trufs, which was afterwards applied, confifted 

of 



S 



172 Strangulated Hernia. 

of an oval ring, made exactly to the fhape of 
the remaining tumour, This kind of trufsfat 
eafy upon the patient, and I fuppofe anfwered 
very well, as I have heard nothing from him 
to the contrary, though it was applied in the 
year 1772. He lived about thirty miles from 
Leeds ; but the operation was performed upon 
him at a fmall alehoufe betwixt Leeds and 
Wakefield, where he was feized with the 
ftrangulation as he was travelling. 

The firft inftance in which I deviated from 
this mode of practice was in the year 1789. 
I did it on the authority of Mr. Pott, being 
defirous of trying the comparative merits of 
thefe two different modes of practice. The 
cafe terminated fatally ; and as it contains 
feveral circumftances worthy of notice, I fhall 
give it at large, that the experienced reader may 
be better enabled to judge, whether the reduc- 
tion of the omentum contributed to the fatal 
event. 

CASE X. 

February ift, 1789. I was called in the 
afternoon to vifit Robert Walker, a poor man, 
aged thirty-feven, who was in great pain 
from a ftrangulated hernia. He had been 

fubje6t 



Strangulated Hernia. 173 

fubject to the hernia for many years. It had 
feveral times been ftrangulated for a few hours, 
according to his account, and could never 
be entirely replaced within the abdomen. The 
ftrangulation at this time had commenced the 
preceding evening at eight o'clock, foon after 
which he had a ftool, but afterwards had no 
evacuation. He vomited fometimes, and had 
a little hiccough. His belly was fomewhat 
tenfe, but not much inflated. His tongue 
rather white. His pulfe foft and calm, at 
fixty-four. The lower part of the tumour in 
the fcrotum was foft; the upper part was 
hard. The fcrotum was fo thin, that I could 
feel the omentum within the hernial fac. 

I ordered a clyfter, made with two drachms 
of tobacco boiled in a pint of water for ten 
minutes, to be injected ; and cloths dipped in 
cold water to be affiduoully applied. I did 
not bleed him as his pulfe was fo foft and 
calm. The clyfter had a powerful effect, pro- 
ducing great ficknefs and vomiting, with a 
cold fweat, during which the pulfe funk to, 
fifty-fix, I attempted during this languor to 
reduce the hernia, but in vain ; not the leaft 
motion was produced by my attempts. 

I now ftrongly recommended the operation, 
and advifed the poor man to go into the Infir- 
mary, 



174 Strangulated Hernia. 

inarv, as the accommodations of his own houfe 
were very bad. My advice did not prevail, fo 
I gave him in the evening fifty drops of tin£l. 
opii, which entirely removed his pain and 
vomiting. The next day the poor man con- 
fented to go into the Infirmary, but not till 
towards evening. The pain had now returned, 
the abdomen was more inflated, and tenfe, 
and the tumour was larger. The operation 
w T as immediately performed. 

Not the leaft quantity of fluid iffued out 
when the hernial fac was opened. A large 
portion of omentum, and a fmaller of inteftine, 
were C:& contents. The former appeared to 
have lain a conliderable time in the hernial 
fac ; for it not only adhered to the fac in 
many places, but alfo had formed in it feveral 
finall pouches, in which it lay depreffed be- 
yond the general level of the fac. The in- 
teftine was dark coloured, but had contracted 
no adhefion. The ftricture was not formed 
by the abdominal ring, but intirely by the 
neck of the hernial fac, into which I could not 
introduce the leaft portion of my finger. 

I was obliged to divide the ring pretty high, 
that I might with fafety divide the neck of the 
fac ; and this laft divifion was effected by cut- 
ting along the groove of a director, till I had 
^ made 



Strangulated Hernia. 175 

made a fufficient aperture for the introduction 
of my finger. As the omentum adhered to 
the fac by little cords, which might eafily be 
divided, I feparated it from the fac, and re- 
duced it immediately after the inteftine. This 
was eafily reduced, but the reduction of the 
omentum gave fome trouble. The omentum 
did not feel brittle, nor appear to be in a 
gangrenous ftate. When the contents of the 
hernia were reduced, fome ferous fluid iffued 
out of the abdomen. A purging clyfter was 
ordered to be injefted ; and he was directed 
to take half an ounce of caftor oil every two 
hours, till a free evacuation Ihould be pro- 
duced. 

February 3d. I found him in a good ftate 
at noon. The clyfters had procured a ftool, 
and after the fecond dofe of the caftor oil he 
had had three evacuations. His pulfe was at 
eighty-fix. 

Notwithftanding thefe favourable appear- 
ances, the fymptoms of inflammation, fuch as 
vomiting, forenefs of the abdomen, with con- 
fiderable pain, returned in the evening. Eight 
ounces of blood were taken from his arm, a 
clyfter was injefted, the ol. ricini was repeat- 
ed, and a large blifter was applied to the 

abdomen. 



176 Strangulated Hernia* 

abdomen. Thefe means afforded no relief, 
and the poor man died at feyen in the morn- 
ing. 

In the evening I examined the contents of 
the abdomen. The inteftines appeared in 
many places inflamed, and adhered to each 
other univerfally. That part which had been 
ftrangulated was of a darker colour. The 
omentum did not cover the anterior furfaee of 
the inteftines as ufual, but paffed down on the 
left fide of the abdomen, collected together 
like a thick rope. The ftrangulated portion 
was now become very brittle, and was dark 
coloured at its inferior part. Bloody ferura 
was contained within the abdomen. 

] E EMARKS.- 

1. This cafe affords a decided inftance, in 
addition to others already publifhed, that the 
neck of the hernial fac is capable of be- 
coming fo contracted as to produce a fatal 
ftrangulation. The contents of the hernia 
feemed to fuffer no injurious preffure from the 
abdominal ring ; for I found no difficulty in 
introducing my finger for the purpofe of divid- 



ing it. 



2. Though 



Strangulated Hernia* 177 

2. Though I think it highly probable b that 
fome degree of inflammatory affection had 
taken place in the whole of the inteftinal canal 
previoufly to the operation; yet from the 
great alteration in the appearance of the 
reduced omentum, compared with its appear- 
ance at the time of the operation, I cannot 
avoid thinking that the injury which that part 
had fuffered was one confiderable caufe of 
the fatal termination. It is poffible that when 
the omentum is in a ftate tending to gangrene* 
though not appearing unfound* it may fuffer 
irreparably from a degree of preffure in the 
reduction, which would not have injured it 
had it been perfectly found. 

3. Though our conjectures refpecting the 
fafety of a patient under a different treatment 
are often, perhaps, the confequence of regret, 
rather than of found judgment ; yet I am con- 
ftrained to think that the operation might 
have had a more favourable iflue, had it been 
performed at an earlier period of the difeafe, 
and had the omentum been left in the fitua- 
tion in which it had probably lain for feveral 
years. 

The gangrened ftate of the omentum comes 
next under confideration. The diftinftion 

N ; between 



17$ ..S^RAtfGUlATfcD H-ERtflA* \ 

between the found and the gangrened part i& 
often fo evident, that a furgeon qannot mif~ 
take the one for the other ; but this is not 
always the cafe. s I have feen the omentum 
have a livid appearance when its texture was 
found ; and I have feen it very little altered 
in colour, when its texture has fhewn it to be 
iii an unfound ftate. In this latter cafe the 
omentum becomes crifp or brittle. I do not 
recollecl: any author who has defcribed this 
ftate of the omentum except Mr. Warner. * 

When the portion of omentum found in 
the hernial fac is, from its difeafed ftate, unfit 
for reduction, it may be tied, cut off, or left 
in the wound to feparate fpontaneoufly. I 
{hall offer what I have obferved refpe6ling 
thefe three different methods of treatment. 

The firft has, I believe, been done without 
proving fatal to the patient. Le Bran and 
others have given inftances of it. But if the 
ligature is made fo tight as to deftroy the cir- 
culation in the part below (which is that kind 
of tying of which I am now fpeaking) the prac- 
ticed extremely dangerous, and ought, in my 
opinion, to be laid afide. Mr. Wilmer ap- 
prehends no danger from it ; but his opinion, 

# Warner's Cafes in Surgery, ed» 3d. p. 1Q2, 193. 

in 



Strangulated Hernia. 179 

in this inftance, is contradi&ed by expe- 
rience. He fays, M When it is necefTary to 
" remove any part of the omentum, there 
" will be no occafion to pafs a ligature ; but 
H if the furgeon choofes to do it, if he is 
44 careful that no part of the inteftine is 
44 included, it is not probable that any par- 
44 ticular inconvenience will arife from it*/* 
Monfieur Pipelet has written an excellent 
memoir on this fubj e6t*fy in which he has 
(hewn from experience the danger of this 
prafitice; But the moft decided condemnation 
of this practice occurs in the writings of Mn 
Pott J. He has with great candour related 
the fatal effeft of fuch a practice in a patient • 
of his own; I faw him perform the opera- 
tion (to which I apprehend he alludes) in 
the year 1758. The patient was in perfe6l 
health $ and had an epiplocele^ which was only 
troublefome by its bulk* The omentum was 
quite found. A tight ligature was put upon 
it, and the part below was cut oftl The fymp- 
toms which fucceeded are thus accurately de- - 
fcribed. " I have feeri a whole train of bad 

•* Obferv aliens on Hernias, p. 78. 

+ Memoires de 1* Academie de Chirurgie, torn. iii. 3Q4, 

J Pott's Works, o&avo edit, vol ii. p, 117. 

K % " fymptoms, 



180 Strangulated Hernia? 

'" fymptoms, fuch as naufea, vomiting, hie* 
" cough, fever, anxiety, reftlefsnefs, great 
" pain in the belly, and an incapacity of fit- 
" ting upright, or even of moving without ex- 
66 quifite pain, precede the death of a man, 
" whofe omentum was tied merelv becaufe 
" of its enlargement," &c. ib. Surely no fur- 
geon, who has read this account, can, with a 
good confcience, apply a tight ligature upon 
any coniiderable portion of omentum in a 
found ftate. 

There is, however, another method of em* 
ploying the ligature, which is not attended 
with the danger above defcribed. I made 
ufe of it in the following cafe with fuccefs. 



C A S E XL 

Henry Taylor, of Thornton about thirty 
miles from Leeds, a flout man, aged thirty- 
four years, had been fubjecl: to afcrotal hernia 
for fome vears, which had feveral times been 
reduced with difficulty. It became prolapfed 
and ftrangulated in the evening of May 5 th, 
1789. He w r as bled, had clyfters injected* 
and was put into the warm bath. On the 
evening of the 7th he fet off for Leeds, to put 

• himfelf 



Strangulated Hernia. i 8 i 

himfelf under my care. He travelled all 
night in a cart, and arrived at Leeds on the 
morning of the 8th. He was much fatigued 
with his journey. I procured a lodging for 
him, and put him to bed immediately. His 
pulfe w T as at one hundred, rather full and 
hard. He had great pain in the hernia and 
abdomen, both which were fo fore, that he 
could fcarcely bear them to be touched. He 
had a frequent vomiting, to allay which he 
had drunk fome gin and water upon the road, 
I took a pound of blood from his arm, and in- 
jected a clyfter made with the decoction of 
tobacco. He became rather ealier, but there 
was no diminution of the tumour. I applied 
cloths dipped in cold water, and threw up the 
fume of tobacco per anum, without fuccefs.— 
At noon I performed the operation. No fluid 
iffiied from the hernial fac when firft opened, 
A large rnafs of omentum lay in the fac, in- 
cluding a portion of inteftine, in fuch a man- 
ner, that it could not be feen till the omentum 
was expanded. The omentum was very livid, 
or rather black, on its exterior furface* Some 
fragments of it within appeared found. The 
found and unfound parts were intermixed, fo 
that there was no line of feparation between 
them. It did not feel brittle. One part of it 

K 3 was 



182 Strangulated' Hebkxa, 

was compa6i and fmooth like the mefentery* 
A filament went off from this part, and adher- 
ed to the peritoneum juft within the ring. 
The inteftine was inflamed, and had contra&ed 
an adhefion to the omentum, about two inches 
in length, and one in breadth. That part of 
the omentum which adhered to the inteftine 
was quite black, but was eafily feparated from 
it by gentle pulling. The ftri<5ture from the 
abdominal ring was not great, for I could with 
eafe introduce my finger for the purpofe of 
conducting the bubonocele knife. There was 
no ftri&ure from the neck of the hernial fac. 
The inteftine was reduced with eafe. 

The great difficulty in this cafe was, how to 
difpofe of the omentum. Its bulk was fuch, 
that when taken out of the hernial fac, it ap-? 
peared, after the reduction of the inteftine, to 
be more than double the quantity which one 
could fuppofe capable of being compreffed 
within the compafs of the fac. It was though t, 
by feme perfons who were prefent at the ope- 
ration, to be fix or eight ounces in weight.- — 
The r'edu6tion of fo difeafed a mafs was out of 
the queftion. To make a tight ligature upon 
it would, as I apprehended, be in effefit to de- 
ftroy my patient. I was by no means fatis^ 
fied to make fb large a wound in the omentum 
9 as 



Strangulated Hernia, 183 

as would be neceflary to extirpate all that was 
prolapfed ; and the difeafed parts were fo in- 
termixed with thofe which appeared to be 
found, that it was impoffible to make a repa- 
ration between them. Indeed, there was fuch a 
gradation between the parts which were clearly 
mortified and thofe which were as clearly in 
a found ftate, that I could not have drawn 
the line of feparation had I attempted it. 
Preffed with thefe difficulties on every fide, I 
determined to leave the omentum as it was, 
covering it with lint fpread with digeftive, and 
over all a large pledget of tow fpread with the 
fame. 

My patient felt himfelf eafy after the ope- 
ration, and had no more vomiting. I ordered 
a purging clyfter to be injected, and half an 
ounce of oL ricini to be given every two hours. 
Some faecal matter was difcharged with the 
clyfter. He took five dofes of the ol. ricini, 
and then ceafed taking it. He had five or 
fix liquid ftools before the next morning, but 
did not difcharge any figured excrement. His 
pulfe intermitted in the evening ; but as he 
had very little pain, and no vomiting, I was 
not uneafv, having; feveral times obferved fuch 
iatermiffion, in acute difeafes, to be a fyntp- 
tom of faburra in the primae vice, and to go off 
after a free -evacuation. 

y 4 I Otl>. 



184 Strangulated Hernia. 

1 Oth. He had paffed a quiet night. Pulfe 
regular, and at ninety-fix. The difcharge by 
ftool having ceafed for fome hours, I dire&ed 
a repetition of the 61. ricini. I defired my 
patient to take no folid food, but to live En- 
tirely upon broth, barley water, gruel, and 
the like. 

11th. Pulfe from feventy-fix to feventy- 
eight, in the morning:. From this time his 
bowels were kept open by the continued ufe 
of ol. ricini, given as occafion required. His 
pulfe had now and then a little intermiffion, 
but this fymptom never continued long. 

About one third part of the omentum was 
caft off in a gangrened ftate j but two thirds 
of it, at the leaft, remained found, and in the 
courfe of a few days this part began to have 
frefti granulations on its furface. 

Notwithstanding the advantage which I 
feemed to have gained by avoiding the hazard 
of any operation upon the omentum, yet it was 
eafy to forefee, that great difficulties would 
arife from fo large a mafs of granulated flefh 
(for fuch it foon became) remaining in the 
wound. It was impoffible to comprefs it 
within the lips of the wound ; and as the in- 
teguments now lay behind it, there was no 
hope that they would ever afcend to form a 

natural 



Strangulated Herkia. 185 

natural covering to fo prominent a part. In 
ruminating upon the different methods of 
treating this incumbrance, I recollected that 
I had often feen deep fiffures made in found 
parts of the body, by the gradual preffure of 
any ^harp-edged fubftance, applied without 
fuch defign, and effected without much pain. 
I therefore determined to attempt cutting 
through the omentum, clofe to the abdomen, 
by the gradual, yet very gentle, preffure of a 
ligature. On the 7th day after the operation 
I began to apply a ligature of waxed filk, but 
in fo gentle a manner as to give no pain. The 
application produced a bluim appearance in b 
the tumour, and made it feel to the patient a 
little benumbed. The ligature was tied in 
fuch a manner, that the patient could at any 
moment unloofe it ; and he was directed fo to 
do, if he mould feel any pain, ficknefs, or 
naufea. 

On the firft day after this application, he 
had fome fhivering, and uneafinefs in his 
belly. His bowels were likewife moved with 
greater difficulty by the ol. ricini. Thefe 
fymptoms were attributed to the ligature, 
which was immediately untied. But upon in- 
quiring into all circumftances, I found that he 
had, contrary to my directions, eaten fome 

flem 



1 $6 Strangulated Hernia. 

flefti meat that day, which I imagined might 
have caufed fome uneafinefs. After two or 
three loofe ftools, thefe complaints ceafed. 1 
urged the neceffitv of a more ftricl: attention 
to his diet, and renewed my requeft that he 
would confine himfelf to broth and light pud- 
ding during the ufe of the ligature. 

I renewed the application every day, infi- 
niiating doffils of lint into the fiffure ; and on 
the 17th day of this procefs I cut through the 
fmall remaining part of the omentum^ which 
had now been nearly divided by the ligature. 
An artery in the centre of the remaining part 
was become fo large as to require the ufe of a 
needle and ligature. By this gentle method 
I fafely removed the mafs of omentum, after 
which the wound healed very fpeedily, and 
my patient returned home fix weeks after the 
operation, the wound being then nearly cica- 
trized. The portion of omentum which I cut 
off weighed five ounces and five drams avoir- 
dupois. • 

The excifion of a portion of omentum in the 
found part has been pra6tifed, and recom- 
mended by fome eminent furgeons. Monlieur 
Caque, chief fargeon of the Hotel Dieu at 
Ilheims, fays, that in nine operations he had 
cut the omentum in its found part without 

ligature, 



Strangulated Hernia. 187 

ligature, and that no unfavourable accident 
had refulted from this treatment *, Mr. Pott 
fpeaks in the ftrongeft terms in favour of this 
method. He fa vs. u The fear of haemorrhage 
" is almoft, if not perfectly, without founda- 
u tion, as I have feveral times experienced." 
And again, " I will not pretend to fay, that 
" there never was a dangerous or fatal flux of 
w blood from the divilion of the omentum 
* c without ligature ; but I can truly fay that 
" I never faw one ; that I have feveral times 
" cut off portions of it without tying, and 
** never had trouble from it of any kind, 
" though I have always made the exeifion in 
" the found part ; and that, from the fuccefs 
* c which has attended it, I mall always con~ 
** tinue to do fo, whenever it ihall become ne- 
" ceffary," Vol. ii. p. 11 6. 118. I have 
twice, and only twice, cut off a pretty large 
portion of omentum in its found part, in the 
operation for the ftrangulated hernia ; and I 
am forry to fay, that in both cafes the reduc- 
tion of the remaining omentum was followed 
by haemorrhage, which nearly proved fatal to 
one of my patients. I will relate the cafes. 

* Memoires de rAcadeaaig de Chirurgie, torn. ili. p. 

407. 

CASE 



188 Strangulated Hernia. 

CASE xil. 

Sept. 16 th, 1795. Mofes Bradford, aged 
fixty-one years, was brought into the General 
Infirmary at Leeds, with a ftrangulated fcrotal 
hernia, 'on the right fide. He had been fub- 
jeQ; to the hernia for feveral years. The 
ftrangulation had commenced in the forenoon 
of the preceding day. He had vomiting, hic- 
cough, fulnefs and tenfion of the abdomen. — 
His tongue was clean and moift. His pulfe 
at feventy. The tumour was very tenfe near 
the ring. The operation was performed at 
three in the afternoon. The contents of the 
hernial fac were a portion of omentum in a 
found ftate, and a portion of inteftine highly 
inflamed. The omentum was of a pyriform 
figure, Its broad part adhered to the bot- 
tom of the fac, and was about the fize of an 
ordinary pear. The upper part had contrac- 
ted no adhefion with the fac, and was about 
the thicknefs of one's little finger. There 
feemed no reafon to doubt that the omentum 
had remained in this ftate far fome years. 

I could not introduce the tip of my fore- 
finger, for the purpofe of dividing the ring and 
neck of the hernial fac, but wag obliged to 

make 



Strangulated Hernia. 189 

make ufe of a dire&or. After an opening was 
made, capable of admitting my finger to pafs 
into the abdomen with eafe, I could not ftill 
reduce the inteftine, until I had divided the 
omentum, which I did at the lower part of 
its neck. Mr. Logan held its upper part be- 
tween his fingers for a fhort time after the di- 
vifion, to fee whether it would bleed ; and as 
no haemorrhage took place, I reduced it, and 
afterwards replaced the inteftine with eafe. I 
removed the remaining part of the omentum 
which adhered to the fac. 

No fooner was the reduction of the intef- 
tine completed, that* florid blood began to 
flow from the abdomen. We could not doubt 
that this haemorrhage proceeded from the di- 
vided omentum, and were forry that we had 
not fuffered it to lie a little longer out of the 
abdomen. The divided part bad been puihed 
up fo high by the inteftine, and, indeed, had 
retired fo readily before the inteftine was re- 
duced, that there was not the leaft probability 
of laying hold of it. 

I ordered fal. amari 3 j. to be taken every 
hour in a cupful of cold water, immediately 
after its folution, and direfted the application 
of cloths, dipped in coldivater,to the abdomen. 

I vifited 



4 



196 &r»A*6t»tA*l5D MeMia, 

I vifited the man again in the evening. Thi 
haemorrhage* which was never conliderablei 
had diminiftied before I left him, and had now 
ceafed. He felt himfelf eafy^ The purging 
fait* which did not fit eafy upon his ftomachj 
was omitted s and the oh ricini was directed in 
Its ftead. Pulfe feventy-four* A purging 
elyfter was injected* 

1 7th, morning* He had taken an ounce 
and a half of the oh ricini, which he had re- 
tained* He had had three filial! ftools* His 
belly was ratlier more tenfe* Pulfe feventy- 
fix. The oh ricini was continued, and the 
elyfter repeated* 

Evening, I found him much worfe* He 
had vomited up all the ol. ricini in the after- 
noon at one copious evacuation. He had & 
frequent hiccough and retching* ■ His belly 
was much inflated* His pulfe was become 
irregular, though not very frequent. I direct- 
ed a elyfter to be injected, made with the 
decofiiion of tobacco, and the following 
draught to be given i 

R, Magne£alb. 9ij. 

Aquae puns cochleare j. vel ij. 

f. hauftus alternis horis fumendus, fuper* 
bibendo cochl. j* fucci limonum. 



8tk 



Strangulated Hernia. 191 

1 8th. Thefe means had afforded my pa- 
tient great relief. His ftomach was fettled, 
and he had had in the night a copious eva- 
cuation by ftool. His belly was now foft and 
flaccid. Pulfe feventy-two. 19th and 20th. 
He continued doing well. His bowels fuf- 
ficiently open. Pulfe feventy. 

2lft. Liquid fseces began to flow through 
the wound, without any previous bad fymp- 
tom. 

22d. I directed a laxative clyfter to be 
given once a day, and laid alide the ufe of pur- 
gatives taken by the mouth. He has natural 
crepitus alvinus from the anus. 

23d. He had lain dry all night, but this 
morning liquid faeces, mixed with air, were 
difcharged through the wound. I directed a 
clyfter to be given night and morning, made 
with a pint of water gruel, and a fpoonful of 
treacle. I alfo directed his diet to be intirely 
liquid, as milk in various forms, broth, &C 
and forbad him to eat bread, pudding, or 
rice. 

November 1 6th. Since the laft report, the 
fize of the wound, and the quantity of fseces 
difcharged by it, have continued to diminiflic 
He has had all along regular ftools per anum, 
except that twice during this period the regu- 
lar 



192 Strangulated Herkia, 

lar difcharge was fomewhat fuppreflfed* at 
which times he complained of pain in the 
belly. A dofe or two of the ol. ricini* with 
the clyfters, relieved him* Upon making a 
ftrict inquiry in the ward* I found that he had 
at both thefe times taken fome folid food. The 
wound is now nearly cicatrized, a fmall aper^ 
ture only remaining, through which a thin 
curdled matter fometimes iffues. He is other- 
wife in good health and fpirits. 

Dec. 1 1th. He was difcharged cured, 
A retention of urine accompanied the ftran* 
gulation in this cafe, which obliged me to have 
recourfe to the catheter during the two firft 
days. After that time his difcharge of urine 
was natural. 

I did not fee this poor man after his dif* 
million from the Infirmary, but was informed, 
that he was foon after feized with violent pain 
in the abdomen, attended with vomiting, and 
died on the fecond day of his illnefs. 



CASE XIII. 

December 26, 1 797* I was defired to vifit 
William Langdale, a journeyman coach-maker, 
aged thirty-five years, who was faid to be 

violently 



Strangulated Hernia. 193 

violently afflicted with the colic. He com- 
plained of great pain in his belly, which was 
aggravated by fits, and was chiefly felt a little 
below the navel. He vomited every thing he 
took, and was coftive. Upon inquiry I found 
a tumour in the fcrotum, of which the man 
had taken no notice, not apprehending it to 
have any connexion with his diforder. I in- 
formed his friends of the true nature of his 
complaint, and advifed them to convey him 
immediately to the Infirmary. My advice 
was followed, and at two o'clock I vifited him 
there in confutation with Mr. Logan. 

The man informed us, that a fwelling fimilar 
to that which we now found, though not fo 
large, had at different times affected him. This 
he had always before been able to reduce, but 
did not remember to have perceived any gug- 
gling noife during the reduction of the pro- 
lapfed part. He feemed quite ignorant of the 
nature of his difeafe, but affured us, that he 
had not a conftant fwelling in the fcrotum or 
groin. The prefent feizure took place foon 
after he rofe out of bed, at two o'clock in the 
morning of the preceding day. From that 
tinre he had had frequent vomiting, with great 
pain in the abdomen, but not much pain in 
the tumour. The abdomen had now a con- 

O fidera* le 



194 Strangulated Hernia* 

fiderable degree of tenfion. His tongue wa& 
white and furred* His pulfe flrong^ arid at 
eighty-fix. 

The tumour was of an unufual form, That 
part of it which lay in the groin had more re- 
femblance to a thickened fpermatic chord, than 
to an ordinary hernia* As the patient re- 
peatedly affirmed, that he had never perceived 
that guggling noife, which ufually accompa- 
nies the reduction of a prolapfed inteftine, 
when upon former attacks he had repr effect 
the rupture ; and as at this attack the pain 
was chiefly felt a little below the navel, we 
thought it not improbable that the hernia 
might be an epiplocele. We determined, 
however, to try the effect of bleeding and the 
tobacco clyfter before we proceeded to the 
Operation. A pint of blood was immediately 
drawn, by opening a vein in each arm at the 
feme time ; and a clyfter made with the de- 
coQion of tobacco was injected. 

We vifited the patient, again at four o'clock ; 
and finding no alteration for the better, I per- 
formed the operation. The hernial fac con* 
tained a good deal of ferous fluid, beiides a 
pretty large portion of inteftine, inveloped 
and completely covered by omentum. The 
neck of the hernial fac, below the abdominal 

ring* 



Strangulated Hernia. 195 

rin°\ formed fo confide r able a ftriclure, that 
I could not introduce the tip of my finger to 
guide the curved biftory. It even required 
ibme force to introduce a dire&or fuitable to 
this occasion. After dividing the neck of the 
hernial fac, I could eafily introduce my finger 
within the abdominal ring, which I alfo di- 
vided fufficiently to permit the reduction of 
the inteftine. 

The omentum was become gangrenous, and 
in one part adhered pretty ftrongly to the in- 
teftine. That part of the inteftine, which had 
been inclofed in the ftriclure made bv the 
neck of the hernial fac, appeared as if it had 
been tied round by a firing. The colour was 
fo much altered by this imprefiion, that we 
were under confide rable apprehenfion of a 
feparation taking place at this part. I en- 
deavoured to reduce the inteftine with all 
poffible gentlenefs, after I had feparated it 
from the omentum; yet, notwithftanding 
all the caution I could ufe, I was much 
afraid that the operation would not preferve 
the life of my patient, even if no injury fhould 
arife from the morbid ftate of the omentum. 

I had always been afraid of large wounds 
of the omentum ; but as the excilion of a 
gangrened portion, by cutting through the 

o % adjacent 



196 Strangulated Herkia, 
adjacent found part, flood fo ftrongly recom- 
mended by Mr. Pott, of whofe judgment I 
had a very high opinion, I determined to fol- 
low his example in this inftance. I cut off, 
therefore, all that -had a morbid appearance, 
and the remainder, as foon-as I ceafed to hold 
it, retired fpontaneoufly into the abdomen. 

A haemorrhage immediately enfued, which, 
from the diftin6t colour of different parts of 
the ftream, evidently confifted both of arterial 
and venous blood. The difcharge of blood 
diminifhed fo much in a fhort time, that I 
ventured to unite the divided integuments, 
through the whole extent of the wound, by 
the interrupted future. I ordered a purging 
clyfter to be injected, and half an ounce of 
ol. ricini to be given every three hours till a 
free evacuation fhould be procured. 

I vifited the patient about two hours after 
the operation, and found himaileep. 

At ten in the evening I was called to him, 
on account of a violent haemorrhage which 
the nurfe had juft difcovered. The blood had 
flowed through his bed upon the floor. I im- 
mediately cut out the ligatures which were in 
the upper part of the wound, both to give a 
free iffue to the blood, and alfo to enable me 



to know the true ftate of the hcemorrhage.- 



The 



Strangulated Hernia. 197 

The blood which now iffued out appeared to 
be venous. It flowed irregularly, fome times 
ceafing for ten or twelve minutes. I applied 
cloths dipped in cold water to the abdomen 
and fcrotum, and kept dabbing the wound 
with a cold wet fpunge. His pulfe was weak, 
and at a hundred and eight. His countenance 
more pale. The belly lefs tenfe. He had had 
one ftool. I left him at half paft eleven, ai 
the haemorrhage had then abated, defiring the 
houfe apothecary, and my fenior pupil, who 
remained with him, to continue the applica- 
tion of the cold cloths till the haemorrhage 
mould ceafe, and to give the ol. ricini every 
three hours. 

27th. The haemorrhage ceafed at half paft 
pne in the morning. At three he was left to 
the care of his nurfe. His pulfe w r as then at 
a hundred and twenty. I faw him at eleven. 
Pulfe a hundred and eight, and weak. Tenfion 
of the abdomen lefs than before the operation, 
but yet too great. Had had two good ftools. 
01. ricini continued. He vomited two or three 
times in the courfe of the day, and was reft- 
lefs. Bellv more tenfe in the evening:. Tongue 
furred. Complained much of thirft: Had 
frequent belchings, and pain in the belly. 

9 3 S8th. 



!£)8 -Strangulated Hernia. 

28th. I found him much better. He had 
had very copious evacuations by ftool. Vo- 
miting had ceafed ; the belchings were dimi- 
nilhed. Pain in the belly abated, but not re- 
moved. Pulfe a hundred and 'two* Coun- 
tenance much improved. He had taken near 
five ounces of the ol. ricini ; ordered it to be 
difcontinued. 

He remained in a very uncertain ftate dur- 
ing the firft fortnight after the operation. His. 
belly tender, and often inflated, particularly 
during the fecond week. His pulfe from 
ninety-fix to a hundred and eight. He had 
no return of the vomiting. He was always 
relieved, whenever the unpleafant fyrnptoms 
became aggravated, by purging him with the 
ol. ricini, thou oh he was never coftive. 

At the end of the fecond week his. tongue 
became clean, his urine of a natural colour, 
his abdomen more foft and eafy, and his pulfe 
varied from eighty-fix to ninety-fix. His 
wound had all this time looked well, being 
foon filled with good granulations. He was 
now permitted to fit up a little every day, but 
was allowed nothing more folid for food than 
boiled pudding. His belly continued tender, 
and fometimes painful, for feVeral weeks, but 
he recovered perfe6tly at laft, and, after his dif~ 

• million* 



Strangulated Hernia. 199 

miffion, followed bis former laborious em- 
ployment. 

REMARKS. 

This cafe clearly (hews, that large wounds 
of the omentum are attended with danger. — 
As the termination was favourable, I am not 
ferry that the operation was performed as Mr. 
Pott and Monfieur Caque have advifed ; but 
I mall never again cut off any large portion of 
omentum, without applying a ligature to every 
bleeding veffel, whether artery or vein, before 
I permit the remainder of the omentum to re- 
tire into the abdomen*. 

1 do not attribute the dangerous fymptoms, 
which continued for a fortnight, to the exci- 
fion of omentum, but rather to the difeafed 
ftate of the inteftine, Had the operation been 
deferred to the fucceeding day, or even for a 
few hours, it is highly probable that the pro* 

* Since tliefe obfervations were written,, Mr. Home 
has pu-blifhed force cafes of ftfangulatecj hernia. In one 
patient^ upon dividing the omentum with a pair of fcif- 
fars, " Two arteries on the cut edge bled fy violently as 
f to require being fecured by ligatures." 

Tranfaclions of a Society for the Improvement of 
Medical and Chirurgical Knowledge, vol. ii. p. 102. 

o 4 lapfed 



200 Strangulated Hernia. 

lapfed part of the inteftine would have fepa«* 
rated from that above the ftriciure. Indeed^ 
our hopes of the poor man's recovery were at 
a very low ebb, when we perceived the irn- 
preffion which the ftric-ture had made upon the 
interline. 

It has been propofed to make the incifion 
in the mortified part of the omentum as near 
as poffibie to the found. But I cannot avoid 
thinking, that thofe who fpeak of fuchan ope- 
ration as always practicable, fpeak under the 
influence of theory, rather than from expe- 
rience. Sometimes the found and m6rtified 
parts are fo intermixed, (as in Cafe X.) that 
it is impoffible to leave the former and remove 
the latter. At other times the gradation of 
appearance, from found to mortified, is fuch, 
that one cannot determine where the. line of 
feparation will lie. 

The laft method of treating a gangrened 
portion of omentum is by leaving it in the 
wound, after reducing what appears clearly to 
be found, if there be any fuch prolapfed. This 
method has anfwered well in three cafes, in 
which I have tried it, and feems to be pecu- 
liarly adapted to thofe cafes, in which the 
omentum has lain for fome time in the hernial 
fac previously to the ftrangulation. In two 

of 



Strangulated Hernia. 201 

of the cafes, the difeafed part was caft off on 
the feventh day after the operation ; and in 
the third cafe, on the eleventh. All the pati- 
ents recovered. 

The remaining part of the operation con- 
lifts in the treatment of the wound, after the 
reduction of the prolapfed parts. The method 
which was perhaps univerfally followed till of 
late, was that of introducing a doffil of lint, 
tied with a thread, into the aperture made by 
dilating the abdominal ring. This was done 
with the view of giving vent to any matter, 
whether blood, ferum, or pus, which might 
require to be difcharged from the abdomen. 
This method I have ufually followed, and am not 
aware that it has ever prevented the recovery 
of a patient. However, I fee no objection to 
the method of uniting the lips of the wound 
by the interrupted future. When there is no- 
thing to be difcharged, it is undoubtedly the 
beft method of treating the wound. It will 
not prevent the drawing away of a ligature 
put upon any bleeding veffel of the omentum ; 
nor intirely prevent a difcharge from the 
abdomen, which may come on foon after the 
operation. What effect it would have had in 
^Bradford's cafe, where the faeces began to 

flow 



%02 Strangulated "Hernia. 

flow from the abdomen on the fifth day, I 

will not take upon me to fay, as I mean to 
lay my experience, rather than my conjectures, 
before the reader. Mr. (now Sir James) Earle 
recommends the including a part of the her- 
nial fac, in the ligature which is ufed to bring 
on the adhefive procefs in the wounded parts. 
I can fay nothing againft this method from 
experience, except that I have twice feen the 
vas deferens lying on the anterior part of the 
fac, which would be in danger of being in- 
cluded in a ligature that took hold of the fac. 
I may add alfo, that it is not neceiiary to 
include the hernial fac in the ligature in order 
to produce a fpeedy union of the wounded 
parts, as I have witnefled. 

The medical treatment of the patient mull 
depend in feme meafure upon the .circum- 
fiances of each cafe, I mail only obferve in 
general, that purging with the milder cathar- 
tics., aided by a very (lender diet, is the belt 
method that I know for removing the inflam- 
matory fymptoms which may fucceed the, 
operation, ■ 



Mlfcellanetrm 



Strangulated Hernia. 203 

Mifcellaneous Obfervations relative to the 
Strangulated Hernia. 

1 . I think it is not a bad general rule, that 
the fmaller the hernia, the lefs hope there is 
of reducing it by the taxis. Long continued 
efforts to reduce a prolapfed inteftine are moll 
likely to fucceed in old and large hernias, 
when no adhefions have taken place. 

2. As a ftrangulation of one fide of an 
inteftine is not a common difeafe, I fliall relate 
an inftance of the complaint, as it may afford 
fome inftruclion to the young practitioner. 

CASE XIV. 

A labouring man, aged fifty years, fubject to 
a fmall fcrotal hernia, which always retired upon 
lying down, had the misfortune to fixike the 
fcrotum and hypogaftrium againft a poft, as 
he was walking in the ftreets in the evening, 
November 28, 1 767. A vomiting immediately 
fupervened, which foon went off, but returned 
in the morning, and continued all day. I faw 
him in the evening. There was no appear- 
ance of a bruife upon the abdomen or fcro- 
tum. The former was fome what tenfe, and 

feemed 



2.04 Strangulated -Hernia. 

ieemecl to. be very painful when prelleci 
There was a very fmall tumaur in the right 
groin, not exceeding the bulk of a cherry. It 
was free from tenfion, though painful when 
touched. It did not retire upon preffure. The 
patient informed me, that the rupture was 
now lefs than it ufed to be, when he was in an 
ere9; pofiure ; but had not retired as ufual 
upon lying down. He feemed to be in great 
pain, for the fweat ran down his face, though 
his fituation was far from being warm. His 
pulfe was about a hundred, but neither full, 
nor tenfe. His tongue x whitifh. His urine 
was difcharged in fmall quantities. 

About fixteen ounces of blood were taken from 
his arm. The cathartic bitter fait was directed 
to be taken in fmall dofes, combined with an 
opiate; and a purging clyfter was injected. 

30th. The pain in the abdomen had 
continued fevere all night. The vomiting 
alio remained. The abdomen was more fwel- 
led, efpecially in the epigaftric region. 

At eleven in thi forenoon he had a pretty 
large (tool, of proper colour and confiftence, 
hut was not relieved by it. Mr. Billam, a 
furgean in Leeds, vifited him along with me 
foon after ibis evacuation. The purging clyf- 
ter v is repeated, and after it a mild clyfter 

was 



Strangulated Hernia. 205 

was injecled. A blifter was directed to be 
applied to the abdomen. Extract, cathartic. 
3j. thebaic, gr. ifs. were given, and the folu- 
tion of purging fait repeated. His pulfe was 
fmall, and at a hundred and twenty. The 
vomiting continued. At nine in the evening 
we vilited him again. He had had a loofe 
ftool, but was not relieved.- He had another 
evacuation in the night; but died about three 
o'clock in the morning. 

I obtained leave to examine the contents of 
the abdomen, which I did in the evening, in 
the prefence of Mr. Lucas, furgeon, and 
others. 

I firft removed the integuments covering 
the fmall tumour. There was a flight protu- 
berance of the peritoneum, appearing juft 
below the abdominal ring, and lying on the 
innerlide of the fpermatic chord. This after- 
wards was found to be a fmall hernial fac ; but 
I did not open it till I had examined the 
contents of the abdomen. The inteftines had 
an inflamed appearance throughout; they 
adhered in many places to the peritoneum* 
and univerfally to each other. They were 
covered by a thick inflammatory exudation, 
which in fome parts appeared to be one- 
eighth of an inch in thicknefs. A large quan- 
tity 



£06 Strangulated Hernia. 

tity of purulent matter was difFufed in the 
abdomen. A.fmall portion of the ileon, not 
more than half the breadth of the inteftine, 
was contained in the fmall hernial fac, and 
adhered fo ftrongly to it, that a hole was 
made in the inteftine by drawing it gently out 
of the fac. The omentum had an inflamed 
appearance, A portion of the ileon adhered 
to the bladder, which alfo appeared inflamed. 

This poor man died about fifty-fix hours 
after he had received the blow. Whether the 
operation for the ftrangulated hernia, if per* 
formed at an early period of the difeafe, 
would have afforded any probability of reco- 
very, I ihail leave to the judgment of others. 
It is of ufe to know that one fide of an intef- 
tine may be ftrangulated, and become gan- 
grened in the hernial fac without any external 
tenfion. That in fuch a cafe, a patient may 
have difcharges of even folid excrement. That 
when a ftrangulation fubfifts, the danger is 
not diminifhed in proportion to the fmallnefs 
of the hernia. That a hernia may retire in 
part, and the remainder fuffer a fatal ftrangu- 
lation. And laftly, that a full and tenfe ftate 
of the pulfe is not a conftant concomitant of 
a highly inflamed ftate of the inteftmes. 

I have 



Strangulated Hernia. 207 

I have related the above cafe from my 
notes, but would not propofe the treatment as 
a model to the young praCti doner. In inflam- 
matory affeftions of the interlines opiates 
ought not, in my prefent opinion, to be given 
early in the difeafe, with the view of abating 
the pain. The effect of purgatives is reftrained 
by them. But it is from the full effe6t of pur- 
gatives that any permanent relief can be ob- 
tained. I have taken no notice of the warm 
bath, though it was directed, as the want of 
accommodations prevented it from being ufed 
in a way likely to be ferviceable. 

3. The importance of operating in an early 
ftage of the difeafe cannot be urged too for^ 
cibly. A mortification will fometimes come 
on before the difeafe has been of long conti- 
nuance, or the fymptoms have become remark- 
ably urgent. An inftru£live inftance of this 
is related by Mr. Wilmer*. 

The delay alfo gives rife to adhejions, w T hicli 
may fruftrate the effect of an operation. 

CASE XV. 

In December 1763, I performed the ope- 
ration for the femoral hernia on a middle aged 

# Obfervations on Herawe, p. 73. 

woman, 



308 Strangulated Hernia. 

woman, the fixth day of the ftrangulationj 
which was the firft of my vifiting her. The 
inteftine and omentom were both prolapfed, 
and adhered fo flrongiy to the peritoneum, 
that they could not be reduced, though a 
large aperture was made through the femoral 
ring. The inteftine burft about twenty-four 
hours after the operation. She died on the 
ninth day after the operation. 

Upon examining the contents of the abdo- 
men after death, I found the whole inteftinal 
canal, except the colon, ftrongly marked with 
figns of preceding inflammation. The ileon, 
part of which had been prolapfed, adhered 
to the peritoneum in many places, to the 
bladder, and to the appendicula vermiformis. 
Where it adhered to the laft, it was completely 
gangrened about the breadth of a milling. 
Upon feparating the parts which adhered to 
each other near Poupart's ligament, a good 
deal of well conditioned pus iffued out, though 
I had never perceived any to flow frorn the 
abdomen during the life of the patient. The 
omentum was collected together like a rope, 
and palled down from the ftomach and colon 
along the root of the mefentery, the fmall 
inteftines lying before it. This fituation of 
the omentum had drawn the lower orifice of 

the 



Strangulated Hernia. 209 

the ftomach almoft into a vertical pofition. 
The tranfverfe arch of the colon was fo much 
comprefled by the omentum, running acrofs 
it, that the iblid faeces were obftru6ted in their 
paflage. The omentum was retained firmly 
in this fituation by the adhefions which it had 
formed with the peritoneum near the femoral 
rin£. The bladder was difcoloured where 
the inteftines adhered to it. 

4. There are cafes upon record of the intef- 
tines fuffering a fatal ftri6ture, by fome natural 
part fixed improperly*, and by preternatu- 
ral cords formed in a manner which we can- 
not explain -f-. A curious inftance of the latter 
kind occurred in a patient who came under 
the care of Mr. Lucas, at the General Infir- 
mary. 

CASE XVI. 

Auguft 1786. An old man was brought 

into the Infirmary with a pretty large fcrotal 

hernia, in a ftate of ftrangulation, in which 

ftate it had been about twenty-four hours., 

The tumour was very painfol when touched. 

After trying the efTeft of a deco&ion of 

tobacco, given by way of clyfter, and cold 

* Phyfical Eflays of Eiin, vol. ii. Art. 28. 

t Memoires cte l'Academie de Cfcirurgie, torn. ill. 

P ftupes, 



'210 Stra&gxjlated Hernia. 

ftupes, Mr. Lucas performed the operations 
A large portion of inteftine was prolapied* 
and bad approached fo near to a ftate of mor- 
tification, that it was of a livid hue, and had 
a cadaverous fmelL The caufe of this fpeedy 
tranfition from a found to a highly difeafed 
■ftate was, a. ftri&ure which the inteftine fuffered 
from a praetefnatural membranous cord, like 
a piece of whip-cord ? which adhered, by its 
extremities, to the oppolite fides of the hernial 
fac* and completely furrounded the inteftine. 
The following (ketch will give fome idea of the 
nature of this circumvolution. 




The outer curved line reprefents a tranf- 
Verfe fefclion of the hernial fac, when divided 
at its .anterior part. a. b. are the extremities 
of the membranous cord, c, the annular aper- 
ture through which the inteftine paffed ? and 
in which it was ftrangulated. The inteftine 
was of its natural colour above the ftri6ture 
formed by this circumvoluted cord ; below, it 
was in the ftate above defcnbed, 

.. » The 



.Strangulated Hernia. 21 1 

The patient began to have a natural dis- 
charge of fseces -about four hours after the 
operation, and had many ftools; but died on 
the fecond day* 

5. When a double hernia prefents itfelf to 
an operator, the cafe becomes very perplexing. 
Inftances of rhis kind ought, therefore, to be 
recorded, to put the young practitioner upon 
his guard. Mr. Wilmer has given a remark- 
able inftance *, I have twice feen the exift- 
ence of this difeafe, and will give a fhort 
account of both cafes, as they differed confl- 
derablv from each other in fome circun> 
fiances. 

CASE XVII. 

September 1 6th, 1 795. While I was operat- 
ing; upon Mofes Bradford, whofe cafe I have al-* 
ready related, John Barrett, aged forty years 5 
was brought into the Infirmary with a ftrangu- 
lated fcrotal hernia. He had been fubjecl to 
a hernia for fome years, and the ftrangulation 
had now fubfifted four days. There was much 
tendon in the tumour, though no external in- 
flammation. He vomited frequently, had fome 

* Pra&ical Obfervations on Hernia^ p. IO5. 

p % hiccough. 



t\t STRANGULATED HeRNIA> 

hiccough, with a fulnefs and tenfion of the 
abdomen. We ftronrfv recommended an im- 
mediate operation, hut the man refufed his 
confent. A clyfter made with decoction 
of tobacco was injefted ; and cloths dipped 
in cold water were frequently applied to the 
tumour, after fprinkling upon it fome crude 
fal ammoniac in powder. Pulfe eighty-fix. 

17th, at nine A. M. The poor man, find- 
ing himfelf worfe, confented to the operation, 
which was immediately performed. His ab- 
domen was more enlarged. His pulfe a hun- 
dred and twenty, 

Upon opening the hernial fac nothing ap- 
peared but omentum, the furface of which 
was fmooth, and the texture apparently found. 
It adhered univerfally to the upper part -of 
the fac, and I could find no aperture of the 
abdominal ring. This ftate of the parts was 
perplexing. 1 now attempted to draw the 
omentum out of the hernial fac, that I might 
have the opportunity of examining more ac- 
curately the ftate of the parts. I was pre- 
vented from removing the omentum com- 
pletely by an adhefion which it had contracted 
with the bottom of the fac. I was able, how* 
ever, to elevate the greater part of it, and this 
elevation enabled me to difcover a fold of the 

inteftinum 



Strangulated Hernia. 213 

mteftinum ileon lving behind the omentum, 
and furrounded by it. The pofterior furface 
of the omentum was fmooth and fhining, form- 
ing the anterior part of an interior hernial fac 
for the inteftine; the pofterior part being 
formed* by the true hernial fac, which alfa 
included the omentum*. Upon tracing this 
interior fac I was led to the aperture through 
which the inteftine had defcended. This aper- 
ture was fo large that I could eafily introduce 
my fore-finger into it. The coats of the 
inteftine were thickened, but had not much of 
an inflammatory appearance. The interior 
fac was complete at its upper part, and was 
there quite diftin6i; from the fac which I had 
firft opened, and in which lay the omentum. 
The interior fee contained inteftine only. The 
omentum feemed to have no communication 
with the abdomen. I divided longitudinally 
the omentum, and the interior hernial fac, 
which was either formed by, or adhered inti- 
mately to, the omentum, I then enlarged 
the aperture of the abdominal ring, and re- 
duced the inteftine, though with fonie diffi- 

* In this cafe the hernial fac was in reality divided 
longitudinally into two cavities by means of the omen- 
tum. From the anterior cavity there was no opening 
into the abdomen. The pofterior cavity opened into the 
abdomen as ufual. 

P 3 eulty, 



2-1 * Strangulated 'Hernia. 

culty, on account of the increafed thicknefs of 
its coats/ I cot off the omentum from every 
part of the exterior fnc. 

If the interior lac,- in this cafe, was formed 
by the omentum, the difeafe muft have fob- 
lifted in this ftate for a confiderable time t 
for the fac appeared to-be as regularly formed 
at its upper part as if no omentum had been 
prolapsed ; and when I introduced my ringer 
into the abdomen through the ring, I had the 
fame fenfation as in a fimple enterocele. If 
the interior fac was not originally formed by 
the omentum, it is difficult to account for the 
appearance of the parts at the bottom of the 
exterior fac. 

This patient recovered extremely well for 
the firft ten days, and was then feized with 
the locked jaw, of which he died at the end of 
the fecond day of the feizure, 

I examined the contents of the abdomen 
after death, but obferved nothing which 
could account for this fatal termination. Every 
thing relative to the hernia feemed to indicate 
the approach of a perfect cure. 

CASE XVIII. 

In January 1 796, 1 was cleiired to vilit Mrs,- 
Brooke of Ilarewood, whom I had fome years 

£g Q 



Strangulated Hernia. 215 
ago cured of a ftrangulated femoral hernia by 
the operation, and who now laboured under 
the fame difeafe on the oppolite fide. The 
ftrangulation had fubfifted three days. She 
•vomited frequently, and had had no ftool ; 
yet the abdomen was foft, her pulfe calm, 
and her tongue clean, 

I immediately performed the operation,. 
There was nothing in the hernial fac but 
omentum, except a large quantity of ferous 
fluid. The omentum was in part gangrened, 
and adhered to the fac. I could find no 
aperture into the abdomen. My patient 
feemed convinced, that the inteftine had been, 
down before I began to perform the opera- 
tion; and from the accurate defcription which 
flie gave me of the different ftates of her dif- 
eafe, I faw no reafon to doubt the truth of 
her conjecture. She affured me,, that during 
the operation, {he had the fenfation which fhe 
was accuftomed to feel whenever the inteftine 
retired into the abdomen. The hernial fac 
was much wrinkled, as if after being dis- 
tended it had fallen into a collapfed ftate, 
I cut off all that part of the omentum which 
appeared difeafed, as well as all that proje6led 
from the hernial fac. That part which ap- 
peared found, and adhered clpfely to the fac, 
I fuffered to remain, left I lhould wound the 

p 4 fac 



/ 



216 Strangulated Hernia. 

fac ; for its irregular wrinkled furface made 
the excifion difficult. 

The patient recovered very well, but the 
hernia returned, and a trufs was applied to 
prevent the inteftine from defcending as ufual. 

In this cafe it feems to me highly probable, 
that the interior furface of the omental fac be- 
came the exterior furface of the inteftinal one. 
Had not the inteftine retired while I was divid- 
ing the hernial fac, I mould have found a double 
hernia* one omental, and the other inteftinal. 

6. When the teftis does not defcend into 
the fcrotum before birth, care fhould be taken 
to prevent the defcent of the teftis from being 
followed by that of the inteftine or omentum, 
in which cafe the difeafe would be formed, 
which is now diftinguifhed by the name of 
hernia congenita. It may feem a contradict 
tion in terms to fay, that I have known a 
hernia congenita firft formed when the pa- 
tient was fixteen years of age. But my 
reader, who underftands the nature of this 
diforder, will know, that the term defcribes a 
diftinft fpecies of hernia, rather than the 
time of its formation *. 

# See an accurate defcription of this difeafe in, Dr. 
Hunter's MedicaLCqmmentaries, part 1ft. 

C A S E 



-Strangulated Hernia. 217 

CASE XIX. 

In the year 1765, I was defired by Mr. 
Billam to vifit along with him a young man, 
aged fixteen years, labouring under a ftrangu- 
lated fcrotal hernia. The right teftis had, a 
ftiort time before the attack of this difeafe, de- 
fcended into the fcrotum. The defcent of the 
teftis was fucceeded by a hernia, which foon 
became ftrangulated. After bleeding he 
took fifty drops of laudanum, divided into 
three dofes. The pain, which he felt in the 
tumour, abated. He fell into a found fleep, 
which continued three or four hours ; and 
upon his awaking, it was found that the her- 
nia had retired. A trufs was applied to pre- 
vent a relapfe. 

The following year, while the trufs was re- 
moved for the purpofe of repairing it, the 
hernia returned, and immediately became 
ftrangulated. Various means were ufed to 
procure a reduction, but without effect. On 
the 4th day of the ftrangulation, I performed 
the operation at the requeft of Mr. Billam, 
and in the prefence of him and Mr. Wynne. 
Both omentum and inteftine lay in the tunica 
vaginalis teftis, which in tnis cafe conftituted 

the 



09 Strangulated - Hernia, 

the hernial fac, They were both of a dark 
colour, but not in a flat© of mortification, ex^» 
cept a fmall part of the extremity of the 
omentum,, of which there was fome doubt.— 
The omentum adhered {lightly bo% to . the in- 
teftine and hernial fac, but they were eafily. 
arated. After the divifion of the abdo- 



minal ring.,- the inteftine was reduced without 



o ; 



heiitation ; but fome difference of opinion, or 
confiderable doubt at leaft, arofe .ref peeling 
the redu&ion of the omentum. The omentum 
was at length reduced without any retrench? 
kient, after the opinion of the majority of the 
furgeons prefent. 

Symptoms of inflammatory affection fuo 
ceeded the operation. The patient was re- 
lieved by bleeding and purging, but died at 
the expiration of a week after the operation. 
The wound had a good afpect during the 
whole of this fubfequent illnefs. 

I obtained leave to examine the contents of 
the abdomen after death, That part of the 
omentum which had been prolapfed was now 
completely mortified, and lay juft above the 
ring, which was healed internally, fo that no 
aperture remained in the' peritoneum. The 
remainder of the omentum adhered in feveral 
places to the inteftines. The fmall inteftines 
m general did not appear much • inflamed ; 



Strangulated Hernia. 219 

but that portion which had been ftrangulated 
-was in a gangrenous ftate. The colon on the 
right fide appeared much inflamed, and in 
many places of a dark colour. The difeafed 
portions of inteftine adhered to the contiguous 
parts. A fmall production of omentum was 
attached to the fpermatic chord, or rather to 
the peritoneum covering it, about an inch 
above the left tefticle. By this attachment 
the tefticle had been prevented from defend- 
ing into the fcrotum. 

7. An Epiplocele is a troublesome difeafe, 
confidered limply, and alfo, as it frequently 
gives rife to an inteftinal hernia. If it is redu- 
cible, no doubt can remain as to the propriety 
of applying a trufs. When irreducible by the 
taxis, it may often, perhaps always, be made 
to retire, if it has contracted no adhefion with 
the hernial fac, I have cured feve rat trouble- 
fome cafes of this kind, by confining my pa- 
tient to bed, giving at the fame time gentle 
laxatives, and enjoining a low diet. In one 
cafe the confinement of a week was fufficient 
to effect my purpofe ; in general, however, it 
Jias required five or fix weeks. The epiplocele, 
upon its flrft defcent, is fometimes attended 
with pain in the abdomen, as well as in the tu- 
mour, 



220 A new Species 

mour,and then greatly refemblesa ftrangulated 
inteftinal hernia* But if the patient can retain 
light food, and purgative medicines, upon his 
ftomach, there is ufually no neceflity for per-* 
forming the operation for the ftrangulated her- 
nia. In this cafe, the pain and tumefaction of 
the abdomen may generally be removed by a 
free evacuation of the bowels. Though every 
fymptom of danger be removed by this treat- 
ment, the ftri&ure up©n the omentum is fome- 
times fo great as to caufe a gangrene of that 
part which is contained in the hernial fac. The 
integuments then become inflamed in a fhort 
time, purulent matter is formed, and the tu- 
mour muft be treated as a common abcefs. See 
Cafe IX. 

A trufs mould always be worn after the re* 
duftion of the omentum. 

8. It fometimes happens, after the cure of 
a ftrangulated hernia, that the rupture does 
not return, but the general refult is otherwife. 

Judging from my own experience, I fhould 
fay* that a larger quantity of inteftine ufually 
defcends, in thofe perfons whole lives have 
been preferved by the operation, but that the 
inteftine in fuch perfans is lefs liable to ftran- 
gulatioa. A well adapted trufs ihould always 

be 



of Scrotal Herxia. £21 

be applied as foon as the wound is cicatrked, 
and will bear the preiTure. 

An Account of a New Species of Scrotal 
Hernia* 

CASE XX. 

November 6th, 1764. I examined the 
body of a child, fifteen months old, who had 
died of & jirangulated fcrotal hernia, in the 
prefence of Dr. Crowther, a phyfician who 
then lived at Leeds. 

The inteftines were not much inflamed, but 
had in general their natural appearance. The 
jejunum and ileon were confiderably inflated 
with air ; but the colon was fo much con- 
tracted, that it looked like a folid cord rather 
than a hollow inteftine. The ceecum, or head 
of the colon, was not to be feen in the abdo- 
men ; for it had defcended through the ab- 
dominal ring, which formed a ftricture upon 
that part of the inteftine where the ileon joins 
it. In the itri6hire was alfo included the root 
of the appendicula vermiformis ; the reft of 
this appendage being ftill in the abdomen. 

Having examined the contents of the ab- 
domen without altering the ftate of the hernia, 
I made a longitudinal divifton of the fcrotum 

OH 



-£23 • A new. Species 

on its right fide, continuing my ineifion the 
whole length of the tumour, and laid bare, as 
I imagined, the hernial fac. This I opened 
towards its inferior part, which was the moll 
prominent ; but it proved to be the tunica 
vaginalis tejiis, containing, together with the 
tefticle, a portion of the true hernial fac. 

This unufual appearance engaged me to 
profecute the diffeftion with great care. I 
found that the tunica vaginalis was continued 
up to the abdominal ring, and incloled the 
hernial fac, adhering to that fac by a loofe 
cellular fubftance, from the ring to within 
half an inch of its inferior extremity. The 
fibres of the cremafter mufcle were evident 
upGn the outfide of the exterior fac, or tunica 
vaginalis. The interior or true hernial fac 
was a production of the peritoneum as ufual* 
and contained only the caecum or head of the 
colon. The ftrangulated part of the interline 
appeared to have been much inflamed, and 
was in fome places become black : it was con- 
fiderably diftended, and was filled with liquid 
feces. Having removed the proper hernial fac, 
I examined the pofterior part of the exterior 
fac a and found it connected with the fpermatic 
veffels in the fame manner as the tunica vagi- 
nalis is, when the teftis has defcended into 

the 



of Scrotal Hernia. 225 

the fcrotum. An additional proof, that the 
exterior fac was the tunica vaginalis* 

From all thefe circuniftances it is evident, 
that this hernia differed both from the com- 
mon fcrotal rupture, in which the hernial fac 
lies on the outfide of the tunica vaginalis ; and 
alfo from the hernia congenita, where the 
prolapfed part comes into contaft with the 
tefticle, having no other hernial fac befides the 
tunica vaginalis. 

To undcrftand the caufe of the hernial fac 
beino* in contact with the tefticle, and fur- 
rounded by the tunica vaginalis., it is lieceflary 
to confider the manner in which this coat of 
the tefticle is originally formed. 

In the foetus a procefs of the peritoneum is 
brought down, through the ring of the exter- 
nal oblique mufcle of the abdomen, by the 
tefticle as it defcends into the fcrotum ; which 
procels forms an oblong bag communicating 
with the cavity of the abdomen, by an aper- 
ture in its upper part. This aperture is in- 
tirely clofed at, or foon after, birth. The 
upper part of the bag then gradually contrafts 
itfelf, till the communication between that 
portion of it w r hich includes the fuperior and 
greater part of the fperniatie chord, and the 

lower part of the bag. which includes the tef- 
ticle 



334 A new Species 

tide and a fmall fhare of the chord, is oblite- 
rated* The lower part of the procefs or bag 
retains its membranous appearance, and is 
called tunica vaginalis tejtis propria ; while 
the upper part becomes an irregular cellular 
fubftance, without any fenfible cavity, dif- 
fufed amongft the fpermatic veffels,, and con- 
needing them together. 

In the hernia which I am defcribing, the 
inteftine was protruded after the aperture in 
the abdomen was clofed ; and therefore the 
peritoneum was carried down along with the 
inteftine, and formed the hernial fac*. It is 
evident alfo, that the hernia muft have been 
produced while the original tunica vaginalis 
remained in the form of a bag as high as the 
abdominal ring ; on which account that tunic 
would receive the hernial fac with its included 

* Mr. Hunter fuppofes (Med. Comment, p. 84.) that. 
a hernia congenita may be formed after the aperture of 
the original tunica vaginalis has been clofed ; the vio- 
lence with which the inteftine is protruded burfting open 
the clofed aperture of that tunic. But it does not feem 
to have occurred to him, that a hernia of the kind I am 
defcribing might be produced, if the peritoneum fhould 
not again be burft open. I have purpofely examined the 
parts in feveral Hill-born children, and have found, that, 
when the aperture of the original tunica vaginalis is 
ctofed, the peritoneum has appeared to be as firm where 
the aperture had been, as in any other adjoining part. 

inteftine. 



Species of Scrotal Hernia. 225 

inteftine, and permit the fac to come into con- 
tact win the tefticle. The proper hernial 
fac, remaining conftantly in its prolapfed ftate, 
contracted an adhefion to the original procefs 
of the peritoneum which furrounded it, ex- 
cept at its inferior extremity : there the ex- 
ternal furface of the hernial fac was fmooth 
and minin°;, as the interior furface of the tu~ 
nica vaginalis is in its natural ftate. 

The mother of this infant informed me, that 
fhe firft perceived the rupture ^ when the child 
was about two months old. As male children 
are often attacked with a fcrotal hernia in the 
firft or fecond month after birth, it is probable 
that the difeafe may often be of this foecies, 
when it comes on at fo early a period of life. 
This kind of fcrotal hernia may; therefore, not 
improperly be called hernia infantilis, as it 
can only exift when the rupture is formed 
while the parts retain the ftate peculiar to 
early infancy. 

The fcrotal hernia may be divided into three 
fpecies, the fpecifie difference of which arifes 
from the ftate of the tunica vaginalis at the 
time of the defcent. I. If the abdominal 
aperture of this procefs is open when the in- 
teftine or omentum is protruded, the rupture 

Q is 



226 Heenia Congenita Umbilicalis. 

is then called hernia congenita*. 2. If the 
upper part of the procefs remains open, but 
the abdominal aperture is clofed, and is capa- 
ble of refifting the force of the protruding part, 
the hernia then becomes of that fpecies which 
I have now defcribed, the hernia infantilis. 
3. If the cavity of the upper part of the 
procefs is obliterated, and the feptum is 
formed a little above the tefticle, as in the 
adult ftate; the hernial fac then defcends on 
the outfide of the tunica vaginalis, and forms 
the moft common fpecies of fcrotal rupture, 
which may with propriety be called hernia 
virilis* 

CASE XXI. 

In November 1772, I was defired to vifit 
an infant born with an uncommon tumour at 
its navel. I found the funis umbilicalis dif- 
tended to the bulk of a hens egg at its infer- 
tion into the abdomen, though it was of its 
ufual thicknefs in every other part. The dif- 

* The term hernia congenita muft be here confidered 
as technical, describing a particular ftate of the parts 
affected, and not implying that the difeafe exifts at the 
birth of the fubject This difeafe ought to be diftin- 
guifhed by the name of hernia congenita fcrotalis- r as 
there is another fpecies of hernia congenita, which the 
leader will find defcribed in the following cafes. 

tenlion 



Hernia Congenita Umbilicalis. 227 

tenfion of this part of the funis had rendered 
its external coat fo tranfparent, that I could, 
clearly difcern through it the folds of the fmall 
inteftines, which h ad been protruded through 
the navel before the child was born. I had 
never feen this fpecies of hernia before ; but 
foon determined what method to purfue for 
the cure of it. 

I immediately reduced the interline, and 
defired an affiftant to hold the funis compreP- 
fed fo near to the abdomen, that the intef- 
tine misrht not return into the hernial fac. 
I procured fome plafter fpread upon leather, 
cut into circular pieces, and laid upon one 
another in a conical form. This comprefs I 
placed upon the navel, after I had brought the 
fkin on each fide of the aperture into contacl, 
and had laid one of the lips a little over the 
other. I then put round the child's abdomen 
a linen belt; and placed upon the navel a 
thick, circular, quilted part, formed about 
two inches from one extremity of the belt. 

This bandage kept the inteftine fecurely 
within the abdomen, and was renewed occa- 
fionally. The funis was feparated about a 
week after birth ; and at the expiration of a 
fortnight from that time the aperture at the 
navel was fo far contracted, that the cryjng of 

Q 5 the 



228 Hernia Congenita Umbilicalis. 
the child, when the bandage was removed, 
did not caufe the leaft protrufion. I thought 
it proper, however, to continue the ufe of the 
bandage a while longer. A fmall fubftance, 
like fungous flefh, projected, after the funis 
had dropped off, about half an inch from the 
bottom of that deprefiion which the navel 
forms. A doffil of lint fpread with cerat. e 
lapide calaminari, and affifted by the preffure 
of the bandage, brought on a complete cica- 
trization. 

I faw the child for the laft time December 
30th. The fungous fubftance had then difap- 
peared, a firm cicatrix covered the navel, and 
the child was perfectly well. 

CASE XXII. 

In the year 1775, I was called to fee a 
new-born child, whofe inteftines had efcaped 
at the navel out of the cavity of the abdomen, 
I found the whole of the fmall inteftines lying 
upon the belly, not inclofed in any fac. The 
midwife informed me, that me had found 
them in this ftate as foon' as the child was 
born, which was about four hours before I 
faw it; but ihe was of opinion, that the 
quantity of inteftine prolapfed had increafed 

fo me what 



Hernia Congenita Umbilicalis. 229 

fo mew hit fince the birth of the child. The 

inteftines had an inflamed appearance. Upon 

examining the funis umbilicalis, I found that 

it had been much diftended near the navel, 

and was now burft. I was fatisfied, therefore, 

that this hernia was fimilar to that defcribed 

in the laft Cafe; and thought it probable, 

that the hernial fac had burft in the delivery. 

I reduced the inteftines immediately, and as 

carefully as I could ; but the child died with-* 

in a few hours after the reduction. 

. The child appeared to be in a very weak 

ftate when I firlt faw it. It had univerfally a 

blue colour, and its face was deformed, 
i 

CASE XXIII. 

In March 1791, a child was brought to my 
houfe, fifteen hours after its birth, having a 
large tumour in the navel-ftring, The funis 
was diftended greatly to the diftance of four 
inches from the body of the child ; and its 
exterior membrane was fo tranfparent, that I 
had no difficulty in difcerning the contents of 
the tumour. Almoft all that part of the intef- 
tmal canal, which, by being attached to the me- 
sentery, is capable of receding from the fpine, 
ieemed to be contained in the dilated part of 

Q3 the 



230 Hernia Congenita Umbilicalis. 

the navel-ftring. I could clearly fee not only 
the fmall interlines, but alfo the colon, with 
the appendicula vermiformis ; yet the aperture 
at the navel was very fmall. 

There was no periftaltie motion in any part 
of the prolapfed interlines*. 

The midwife had very properly tied the 
navel-ftring beyond the dilated part, fo as not 
in the leaft to injure the interlines. 

I found it difficult to reduce, the prolapfed 
parts ; but by gentle preffure I made them all 
return into the abdomen in the fpace of about 
half an hour. I wrapped fome flat tape round 
the dilated part of the navel-ftring; and ap- 
plied a belt, quilted with wool, near one of its 
extremities, round the belly of the child,, that 

# The want of periftaltic motion in the inteitines 
I attributed to the eompreffion which they differed at 
the entrance of the hernial fac. I have often felt this 
aperture at the navel more dilated in an exomphalos 
which did not exceed the fize of a common plum. The 
periftaltic motion of the inteitines remains in the pro- 
lapfed ftate_, provided they are not compreffed at their 
exit from the abdomen. I once iaw a remarkable in- 
ffance of this in a woman who had an extremely large 
femoral hernia. The integuments were rendered fo 
thin by the great diftention which they differed, that 
the periftaltic motion of the inteitines might very dif- 
tinctly be perceived. The loweft part of this hernia 
extended to the middle of the patient's thigh. 

I might 



New Truss' for the Exomphalos. 23 i 

I might keep up an eafy compreffion upon 
the navel. 

The hernia did not return, but the child 
became uneafv after the redu&ion; and, 
although it had two natural ftools, yet it died 
about forty-eight hours after the operation. 



Defcription of a New Trufs for the 

ExOMPHALOS. 

WHILE I am upon the fubjefl of Hernia., 
I think I (hall confer a benefit on thofe who 
are afflicted with the Exomphalos, by recom- 
mending a trufs invented for that complaint 
by an ingenious mechanic in Leeds, I have 
applied it both to infants v and adults with 
invariable fuccefs ; and I think it to be greatly 
fuperior to any kind of trufs hitherto ufed for 
that diforder. With the leave of the maker 
I have pr.efented my reader with a front view 
of it. It confifts of two pieces of thin elaftic 
fteel, which furround the fides of the abdo- 
men, and nearly meet behind. At their ante- 
rior extremity they form conjointly an oval 
ring, to one fide of W'hich is fattened a fpring 
of fteel of the form reprefentecL At the end 

q 4? of 



232 New Truss von the Exomphalos. 

of this fpring is placed the pad or bolder that 
preffes upon the hernia. By the elafticity of 
this fpring the hernia is reprefied in every 
polition of the body, and is thereby retained 
conftantly within the abdomen. A piece of 
callico or jean is faftened to each fide of the 
oval ring, having a continued loop at its 
edge, through which a piece of tape is put 
that may be tied behind the body. This con- 
trivance helps to preferve the inftrument 
fteady in its proper lituation. 

The annexed plate will fufficiently explain 
the ftruclure of the principal parts of this 
inftrument* 



To fade &xoe 232. 



TL.6. 




J4 TMITSSjfom the JEXStMFSLlWS^ 
^ — Inrenf eel lw 

TK.T7SS 3IAJKE1L, 



[ 233 ] 

CHAP. IV. 

Of the Fungus H^matodes. 



case I. 

JUNE 2 1 ft, 1 780, William Campinet, aged 
twenty-one years, a flout young man, by trade 
a ftone mafon, was brought into the General 
Infirmary, on account of a very large tumour 
on the iniide of the right thigh and knee. 
Upon inquiry he gave the following account 
of his cafe. 

About two years before that time he per- 
ceived a fmall fwelling, the fize of the laft joint 
of his thumb, on the infide of the right knee, 
not far from the patella. This tumour was 
moveable, and gave no impediment to the 
motion of the joint: it was not difcoloured, 
but was painfalVhen moved or preffed upon. 
It continued in this ftate half a }^ear; and 
then, the man having hurt his knee by falling 
againft a ftone, it gradually increafed in bulk, 
but did not exceed the fize of an egg. The 
fkin was now difcoloured with blue fpecka, 

which 



234- Fungus H^matodes. 

which he took to be veins. He could ftill 
walk with eafe, and follow his bufinefs ; but 
eould not bear to kneel upon that knee. 

Two months before his admiffion into the 
Infirmary, he fell from a piece of wood, 
placed about a yard from the ground, and 
violently bent the difeaied knee ; but did not 
ftrike it againft any thing. The tumour 
began immediately to enlarge ; and, within a 
few hours, extended half way up his thigh, on 
the inner fide of the limb. About a fortnight 
after this laft accident, the ikin bur ft at the 
loweft part of the tumour, and difcharged 
fome blood. A dark-coloured fungus, about 
the fize of a pigeon's egg, appeared and re- 
mained at this part. A few weeks after the 
appearance of this fungus, the fkin burft in 
another part of the large tumour, - and dif- 
charged fome blood. From the fiflhre arofe 
another fungus, which had increafed in the 
courfe of the laft week to the fize of a finall 
melon ; and now meafured eight inches over, 
between the oppofite parts of its bafe. Blood 
frequently iffued from the bafe of this fungus, 
chiefly when the man hung down his leg. 
, The whole tumour was now of an enor^ 
mous fize. It meafured nineteen inches acrofs, 
"£~ when. 



Fungus Hjsmatodes. 235 

when the meafure was carried over the fungus 
laft defcribed. Fi*om its higheft part in the 
thigh to the loweft part juft below the knee, 
it meafured feventeen inches, without includ- 
ing the fungus. The bafe of the tumour at the 
knee, exclufive of that part which ran up the 
thigh, meafured twenty-four inches in circum- 
ference. The tumour became narrower as it 
afcended the thigh ; and terminated obtufely 
about the mid-way between the knee and the 
groin. It did not furround the thigh ; but 
was (ituated on the inner ride of the limb, and 
was diftinclly defined. There was no fwelling 
in the ham, nor within the capfular ligament; 
but the leg, knee, and thigh, appeared found 
where they were not occupied by the tumour. 
The fkin, covering the tumour, was livid in 
fome places, and had feveral fiffures and 
fmall ulcerations upon it ; but had not burft 
afunder, except in the two places above de- 
fcribed. The tumour was foft, and gave a 
fenfation of fome contained fluid, when gently 
preffed with the hands alternately in oppofite 
directions. 

The patient affured me, that he had walked, 
without pain in his knee, a week before his 
admiffion into the Infirmary : and he feemed 
perfuaded, that he could now walk, if he 

durft 



' c 236 Fungus H^matobes.. 

durft venture to put himfelf into an eredc pof- 
ture. He had come twenty-two miles m a 
pofl-chaife; and had loll very little blood by 
his leg being laid upon the cufhion. He com- 
plained of the greateft uneafinefs in the high- 
eft part of the tumour. It had become hot 
and painful in the night time, for Tome days 
pafL His pulfe beat a hundred and fourteen 
ftrokes in a minute ; and was rather tenfe, but 
not full. His tongue was clean. He had no 
thirft. His appetite had been good till within 
the laft few days. He did not remember to 
have felt at any time a pulfation in the tu- 
mour. 

June 2 2d. I called a confultation of my 
colleagues at the Infirmary: the refult of 
which was, that the tumour mould be laid 
open by cutting off a portion of the diftended 
integuments; and that, after removing the 
contents, if the fac mould be found in a found 
ftate, the difeafe mould be treated as a fimpie 
wound; but that, if the containing parts 
mould be in a morbid flate, the limb mould 
be immediately amputated. 

As the patient had borne fo long a journey 
the preceding day without apparent injury, 
we did not expect any inconvenience from 
removing him out of his ward into the opera- 
tion- 



FuXGUS HXMATODES. 237 

tion-room, which was (ituated at a fmall dis- 
tance, and upon the fame floor. However, 
the man loft fo much blood from the removal, 
that he fainted while we were applying the 
tourniquet. As foon as he had recovered 
from his deliquium, I made an oval incilion 
through the whole of the tumour longitudi- 
rially, and removed a large portion of the mor- 
bid integuments. 

The tumour contained a very large Quantity 
of a fubftance not much unlike coagulated 
blood; but more nearly refembling the medul- 
lary part of the brain, in its conliftence and 
oily nature. ' It was of a variegated reddiili 
colour, in fome parts approaching to white ; 
and, as blood ifl'ued from every part of it when 
bruifed, I judged it to be uniformly organized. 
This mafs was partly diffufed through the 
circumjacent parts in innumerable pouches, to 
which it adhered ; and was partly contained 
in a large fac of an aponeurotic texture. There 
was a great and univerial effiifion of blood 
from the internal furface of the fac, and from 
the pouches containing this morbid mafs. 

The difeafed ftate of the containing parts, 
and the connexion of the fac with the capfular 
ligament of the knee, put an end to our idea 
of faving the limb. Had the appearance 

been 



238 Fungus Kzematopes. 

been more favourable than it was, yet the 
violent effufion of blood forbad all hope of 
fuccefs but by amputation. I immediately, 
therefore, performed the operation ; and found 
all the mufcles in a found ftate, except thofe 
on the inner part of the thigh, which had been 
In contact with the morbid fabftance forming 
the tumour. Thefe, for a confiderable depth, 
w r ere of a brown colour, and fofter confiftence. 
The principal artery was in a found ftate. I 
was obliged to take up feveral frnall veffels ; 
fome of which were near the furface, on the 
inner fide of the thigh ; and paffed through a 
part fo much difeafed, that we could not ascer- 
tain whether it was mufcle or adipofe mem- 
brane. As the cavity of the fac became very 
narrow and {hallow, at its higheft part, I made 
the circular inciiion through the integuments, 
about two inches below its higheft part ; con- 
ceiving that this frnall portion of the cavity 
would foon become a clean fore, and caufe 
no impediment to the cure. 

As foon as the patient was placed in bed, 
I examined the amputated limb, that I might 
more clearly fee the feat of the tumour, and- 
afcertain the ftate of the parts about the 
knee. 

That portion of the vq/ius interims femoris, 

which 



Fungus Hjematodes. 239 

which remained in the amputated part of the 
thigh, was become brown, and much fofter 
than the other mufcles; which \*ere in a very 
found and robuft ftate. There were many 
fmall portions of extravafated blood, lodging 
in the fubftance of this mufcle. The fac was 
formed by the aponeurotic covering of the 
mufcle ; and had its inferior termination 
where the aponeurofis begins to make the outer 
layer of the capfular ligament of the knee. 
The two fungous fubftances, which I have 
already defcri bed, appeared to have been only 
extenfions of the morbid mafs, where this 
had made its way through the fac and the 
integuments. The joint of the knee and muf- 
cles of the leg were perfectly found. 

The poor man was very low after the opera- 
tion, and complained of great pain in the 
abdomen. This pain was accompanied with 
a ftrong pulfation in the aoria^ which might 
readily be felt by laying one's hand upon the 
abdomen. I gave him immediately tin&. 
opii g tts xxx. and directed him to drink for 
nourishment barley water and thin broth. 
He was often fick in the courfe of the after- 
noon; and vomited up the barley water. The 
pulfe at his wrift was fo weak after the opera- 
tion, 



240 Fungus ILematodes. 

tion, that it could fcarcely be felt; The pain 

in the abdomen abated in a few hours. 

At four P. M. I ordered the following 
draught to be given every two or three hours; 
with wine whey for common drink : 
R Aq. purae £j. 
Sp e pirnent. gij. 
Conf. aromatic. 9j. m. 

I viiited him again in the evening; and, 
finding the vomiting ftill to continue, though 
his ficknefs was fomewhat abated, I ordered 
tincl. car dam. comp. 51J. diluted with three 
times its quantity of water, inftead of the for- 
mer draughts. 

June 23d. I was called to fee him betwixt 
four and five in the morning. He had an un- 
eafinefs in his throat, accompanied with afenfe 
of fufFocation, which awaked him frequently 
when he fell afleep. He was likewife troubled 
with the hiccough ; and threw up every thing 
that he took. His pulfe w r as too frequent to 
be counted. His countenance, however, was 
fomewhat improved. The (lump was quite 
eafy. I directed him to take occafionally two 
drops of effential oil of cinnamon, upon a 
lump of fugar ; and ordered, for his common 
beverage, the belt French brandy, diluted 

with 



Fungus. ILfcMATODES* 241 

with three times its quantity of water, in which 
as much cinnamon had been previoufly boiled 
as would make it gratefuk 

A cataplafm was laid upon the region of 
the ftomach* corififting of theriac, androm. 
%]. aq. amnion. 3 ij. 

Nine, A. M. He had riot vomited fmce 
he began to drink the brandy diluted with 
decoction of cinnamon. His pulfe was at a 
hundred and forty-two; The hiccough ftill 
affected him a little after talking; 

Four* Pi M; Pulfe a hundred and thirty* 
fix. No vomiting. Tongue rather dry. 
Ordered veal broth for food. He had had 
no ftool fmce his admiffion into the Infirmary* 
yet was in a ftate of fuch extreme debility 
from inanition* that I thought it heft to delay 
the ufe of laxatives in any form* I did not 
give him an opiate to»day 5 as he had no pain 
in the ftump : but as the fpafmodic affe6tions 
of his throat and ftomach had beeh fo confi- 
de rably relieved by the grateful ftimulants, 
which he had taken* I directed them to be 
Continued. 

24th. Pulfe a hundred and thirty^two* and 
fomewhat fuller. Tongue dry. He had not 
got much fleep in the night* yet he feemed 
better. Diet continued. 

R 25th. 



242 Fungus Hjematobes. 

25th. Pulfe the fame. The nurfe {hewed 
me a broad livid fpot upon his back, juft 
above the nates, which was evidently an inci- 
pient mortification. I ordered that cloths 
wet with aq. ammon. aeet. ihould be kept con- 
ftantly applied to the part affecled. The de- 
coftion of bark, made warm with the fpirituous 
tincture, was directed to be given in the dofe 
of three fpoonfuls every two hours. 

26th. Pulfe a hundred and fixteen. The 
progrefs of the mortification was flopped. 

27th. Pulfe a hundred and twelve. He 
began to have an appetite for food ; and was 
allowed to take pudding and broth. The 
wound had a glofiy appearance. A good 
deal of pus was difcharged from the interfaces 
of the mufcles. 

28th. Pulfe a hundred and ten. His 
tongue was more moid and clean. A little 
flefh meat was allowed for his dinner. 

His countenance was improved. The upper- 
moft part of the longitudinal wound (which 
had been the extremity of the iac) was healed 
to the extent of an inch : the reft of it re* 
mained floughy, and was dreffed with a 
digeftive ointment. 

From this time the granulations of flefh 
upon the flump became good ; the progrefs of 

• healing 



PtJNGUS JLematodes. 243 

healing was favourable, and the cicatrization 
was nearly completed* at the expiration of the 
fixth week after the operation ; when a new 
iburce of trouble engaged my attention. 

That fmall and fuperricial part of the great 
fee, which I had left at its fuperior extremity, 
from an unwillingnefs to amputate more of 
the thigh than appeared neceffary to be re- 
moved, was now healed : but there had gra- 
dually rifen at the low r er and inner part of the 
thigh, beneath the cicatrix, a tumour which 
was now about four inches in length, and 
between two and three inches in breadth. 
This contained a foft fubftance, exactly fimilar, 
as far as the touch could difcover, to that 
which had filled the large fac. This tumour 
was painful ; and now difcharged, fometimes 
a bloody ferum, and fometimes dark coloured 
blood, through four or five fmall orifices or 
fifliires in the cicatrix. 

Not } r et fully aware of the obftinate nature 
of this difeafe, I hoped to produce good gra- 
nulations from the internal furface of this 
tumour, and to cure my patient, by expofing 
that furface to the air. I thought it right, at 
any rate, to make trial of this method; being 
extremely unwilling to proceed, without abfo- 
lute neceffity, to a fecond amputation. 

R 2 Auguft 



244 Fungus ILema^odes, 

Auguft 3d. I made a longitudinal inciiion 
through the whole extent of the tumour ; and 
removed the fubftance which it contained. This- 
fubftance was exaclly ftmilar to that which 
occupied the large tumour, and which I have 
already defcribed. Some frem blood was- 
found in this as well as in the large tumour. 
When I had intirely removed the contents 
of the tumour, the cells, in which the morbid 
fubftance bad lodged, bled freely ; although 
no diftinct blood-veffel was vifible. The 
blood refembled that of the veins in colour^ 
and flowed *more copiotrfly when the upper 
part of the thigh was compreffed, than when 
it lay (till without prefiure. The wound wa& 
filled with lint, and covered with a pledget 
of cerate. 

No advantage, however, was obtained by 
laying open the tumour. The interior furface 
was found to be in too morbid a ftate tc* 
produce found granulations^ Blood conti- 
nued to ooze out of the wound for a few 
days. The interior furface then became 
covered with a blackifh fubftance^ which gra- 
dually extended itfelf, and formed a new 
fungus. A variety of efcharotics were applied*, 
with the view of deftroying the fungus and the 
morbid furface of the wound* But in vain,: 

The 



Fungus Hjematqdes. 245 

The growth of the fungus always exceeded 
the quantity deftroyed. Undiluted oil of 
vitriol, applied liberally, had very little effect. 

I was now reduced to the necefiity, either of 
removing the whole morbid part by excifion ; 
or of performing a fecond amputation. The 
difeafed part was perceptibly circumfcribed, 
as well as fuperficial ; and therefore, upon a 
confultation with my colleagues, it was de- 
termined to attempt the removal of the dif- 
eafed part without amputation. 

26th. No fooner was the thigh railed 
from the bed, for the purpofe of applying 
a tourniquet, than a copious haemorrhage 
took place. The tourniquet w r as applied with 
all poffible expedition ;-and I began to remove 
the fungous fubftance : but every attempt to 
do this increafed the hemorrhage, fo that we 
were compelled to apply a fecond tourniquet. 
The greateft comprefllon, which we could 
make, was not fufficient to put an entire flop 
to the bleeding. 

Upon examining the wound carefully, when 
the contained fubftance was removed, we 
found the mufcular fleih degenerated into a 
hard mafs, which felt fomewhat like cartilage. 
The adipofe membrane was alio difeafed, and 
was formed into large cells or pouches, in 

r 3 - which 



$46 Fungus H&matodes. 

which the fungous fubftance had been lodged* 
This examination convinced us, that the 
patient could not be faved from immediate 
death, but by a fecond amputation ; which 
was immediately performed above the difeafed 
part of the thigh, 

Every part of the thigh above the incifion 
appeared to be in a found ftate, except the 
principal artery, This was filled with matter, 
fomewhat refembling ftiff coagulated blood, 
which prevented the blood from flowing 
through the extremity of the divided veflel. 
The infide of the artery, w r hen touched with 
the point of a fcalpel, felt hard; and gave 
a found refembling that which arifes from 
gently fcraping a bone f The principal vein 
was pervious, and in its natural ftate, We had 
not occafion to take up more than two fmall 
arteries. The ftump was cjrefied after Mr, 
Alanfon's method, by bringing the divided 
parts as nearly into contact as cquld \)e 7 an4 
without the application of lint? 

My patient was fo much exhaufted by the 
haemorrhages which had happened previoufly 
to the operation, and during the firft ftage 
of it, that, for a fhort time, he was deprived 
of the ufe of his right arm, and could fcareely 

fpeak 



Fungus H^matodes. 547 

fpeak articulately. He was very faint ; but 
had no deliquium, as at the former amputation. 
He complained of great pain at his navel. 
I gave him tinB. opii g tts 40, in a cordial 
draught ; but he fwallowed it with fome diffi- 
culty. 

In the evening his pulfe was tremulous, 
and could not be diftin6tly counted. He had 
regained, in a great meafure, the ufe of his 
right arm ; but he ftill faultered in fpeaking. 
The pain at his navel was much abated. He 
vomited frequently ; but had no hiccough, nor 
difficulty in breathing. I directed him to 
take the deco6lion of bark, with the addition 
of a little of the tin6lure of bark ; and to 
drink now and then of the deco6lion of cinna- 
mon with French brandy. 

27th. 8. A. M. I found him very low. The 
diluted brandy, which had been fo grateful 
and beneficial to him before, was now become 
unpleafant; fo that the fmell of it excited 
retchings. I ordered him to drink a little 
ale whenever he chofe, as that was the 
liquor for which he had now the greateft 
defire. His pulfe could not be counted ; the 
faultering in fpeaking continued, and his 
countenance was very languid. 

Five P. M. Pulfe a hundred and forty-five. 

b 4 The 



248 Fungus ILematodes. 

The vomiting had ceafed, and all the other- 
iyniDtoms of extreme debility were abated. 

The ligatures were caft off before the 
expiration of a fortnight after the operation. 
The wound looked glofiy, but continued tq , 
contra6t in its dinienfion as faft as could be 
expected. He had had at times, fince the 
laft amputation, a little difficulty in breath- 
ing, attended with pain in the thorax ; but now 
he began to complain of a troublefome cough, 
which difturbed him chiefly in the night-time. 
The weather was very hot, and he perfpired 
profufely at nights. A diarrhaea came on, 
but was foon checked by giving him a decoc- 
tion of logwood along with that of the bark. 
The EMs\ vitriol, acid, abated his profufe perf* 
piration. His cough became lefs troublefome, 
and he breathed better. He was allowed to fit 
up in his chair as much as he could bear with- 
out fatigue. He was ufually chearful. He was 
allowed a little flefh meat at dinner, three or 
four times a week; and three half-pints of 
ale in the courfe of the day. His breakfaft 
and fupper confifted of milk porridge, or, 
hafty pudding made with oatmeal and water. 
As foon as he was able to be removed, he. was 
fent home into the country. I was afterwards 
informed., that his cough never left him, and 

that; 



Fukgus Hjematodes. 249 

that he died confumptive about half a year 
after he had left the Infirmary. 

REMARKS. 

In this Cafe, the large mafs, conftituting 
the tumour, appears to have been originally 
formed by an extravafated fluid, which in a 
(hort time became organized. It is not to 
be fuppofed, that a tumour coming on imme- 
diately after a violent fprain, and, in the 
eourfe of a few hours, extending itfelf from the 
knee halfway up the thigh ? could be formed 
in any other w 7 ay than by the rupture of fome 
yeffels, pouring out their fluid contents into 
$he cellular fubftance of the thigh. But of 
what nature was this fluid ? We kiwy that 
pure blood will remain extravafated for a long- 
time unchanged. The fubftance found in this 
patient's thigh had not the appearance of pure 
coagulated blood. It was indeed chiefly, but 
not uniformly, of a red colour; and when 
handled it felt rather like the medulla of the 
))rain, than coagulated blood, being of a 
confidence fomewhat unftuous. Was it blood 
mixed with a large proportion pf lymph ? 
The texture of the fubftance might lead to this 
fuppofitioiij which receives ftrength from the 

confider- 



i250 Fungus Hjematodes. 

confide ration, that the tumour was lituated 
in that part of the thigh where the largeft 
lymphatic veflels are found. 

An ingenious friend of mine has fuggefted, 
that the aponeurotic expanfion covering the 
fmall tumour on the knee, was lacerated by 
the fall, which fet the fungus confined beneath 
it at liberty ; and that from the violence done 
to this fubftance, proceeded the effufion, 
which occasioned the foft tumour in the thigh, 
fo fuddenly formed after the accident. 

Whatever the fluid was originally, it ap- 
peared with fufficient clearnefs to have 
become organized ; for the contents of the 
tumour bled freely wherever they were 
broken by the hand. 

The growth of this fungus was not prevent-* 
ed by the ftrong aponeurofis w r hich covers 
the mufcles of the thigh; for that covering 
was firft diftended, and then ruptured in two 
places by the fungus. 

Where the fungus was expofed to the air s 
its colour was much darker, and it appeared 
there more like coagulated blood than in its 
interior part, the colour of which was fome^ 
what variegated. 

All the parts which lay contiguous to the 
fungus had a morbid appearance. The muf* 

cular 



Fungus Hematodes. 251 

eular fibres were become brown, and indiStinct. 
The adipofe membrane formed a variety of 
jdiftincl pouches, filled with the fungus, the 
furfac.es of which bled freely when the fungus 
was removed. The aponeurosis had loft its 
natural glofs, and had acquired a brownifh hue. 

It deferves to be noticed, that at the fecond 
amputation, the haemorrhage from the morbid 
fungus could not be reftrained, by the appli- 
cation of two tourniquets to the thigh ; yet, 
after the amputation of the Stump, there was 
no difficulty in reftraining the hemorrhage 
from the veffels of the thigh, by the ufual 
preffure of one tourniquet. As the fungus 
was Situated at the extremity of the ftump, 
it was highly improbable, I might fay im- 
poffible, that the haemorrhage Should have 
continued from the veins, in the degree in 
which it did continue, without fome fupply 
from the arterial fyftem. 

It appears from this inftance, which is not 
a folitary one, that the preffure of the tour-* 
niquet upon the thigh in amputation, (and 
the preffure in this cafe was much greater 
than ufual) does not completely obftrucl the 
paffage of blood in the arteries : it only di- 
minifties fo much the force of the current, 
&s to enable the veffels, when in a found Slate, 

to 



Mi Fungus 'Eematode.s, 

to exert their natural contraQiIe power, fo 
effectually as to prevent haemorrhage. 

The contractile power of a found artery is 
great. It is very common" to fee an artery 
bleed copioufly when imperfectly divided, yet 
to ceafe bleeding immediately, or in a very 
ihort time after a complete divifion, It would 
feern that this natural contractility of the 
capillary veffels conftituting the fungus was 
greatly diminimed, as a haemorrhage from 
them could not be retrained by any degree 
of preffure which we could make upon the 
fiiperior part of the Umb.^ 

As thjs is a difeafe which has not hitherto 
been defcribed by any author, with whofe 

writings 

* I do not recollect to have met with an obfervation 
of this curious circumftance in any author whom I have 
confulted. Yet I have feen the fame occurrence more 
than once. 

A woman was admitted into the General Infirmary^ 
on account of a tumour near the ancle,, which had 
arifen from a blow given by the foot of a perfon who 
was infane. When the tumour was opened, the con 7 
tents had the appearance of coagulated blood. Upon 
attempting the removal of any part of the contained 
fubftance, a confiderable haemorrhage enfued, which 
.could not be fupprefled by the application of two. tour- 
niquets. In confederation of the morbid ftate of the 
parts, it wasjudgedneceifary to amputate the leg. After 
amputation, the divided veflels ihewed no greater tendeiir 
cy to hemorrhage than in ordinary cafes of amputation. 
o This 



Fungus PLematodes. 253 

writings I am acquainted, I have taken the 
liberty of calling it Fungus liczmatocles, a 
name as expreffive of its character as any I 
could devife. 

In my remarks on this Cafe, I have ventured 
out of the path of practical obfervation, and 
have wandered into that of theory. The fa6ls 
are ftated faithfully ; but I am not anxious 
about the theoretical reafomng, which forced 
itfelf upon my mind, in a review of this 
curious Cafe. If any of my readers can give 
a more fatisfaclory explanation of the pheno- 
mena, I am content. 

Pulmonary consumption is fometimes the 
confequence of violent ha^morrhagej when 
the patient is greatly reduced by the evacu- 
ation, efpecially if the hemorrhage has been 
repeatedly renewed, I have feen this happen 
fo often in patients who - had no apparent 
tendency to confumption, that I cannot 
doubt of the fact, though I can fee no relation 
between the caufe and effe6L 

This Cafe occurred before 1 was acquainted with the 
nature of the difeafe to which I have given the name of 
Fungus Hamatodes. I am now, upon recollecting the 
circumilances of the cafe, inclined to think, that the 
tumour in this woman's lea: was of the fame kind as 
that which I have jufi defcribed. 

Case 



254 FtfXGUS Hj£mATOI>E^ 

CASE IL 

July 20th, 1785, Tvifited Mrs. Dean, of 
Linton, a maiden lady, aged fifty-four years ; 
who had a conliderahle enlargement of the left 
mamma. She informed me* that, about 
three months before, as ihe was exerting 
herfelf in railing her father (who was fuper- 
annuated, and confined to his bed) fhe felt a 
fenfation as if fomething had cracked in her 
breaft. Within a few days after this accident, 
me perceived a fmall tumour in the part* 
about the fize of a hazel-nut. This tumour 
increafed gradually in bulk; w r as hard, and 
moveable. When it had arrived at the v fize 
of an apple, it was fliewn to Mr. Moorhoufe, 
a furgeon at Skipton ; who coniidered it as 
an occult cancer, and advifed extirpation, 
Afterwards Mr. Prieftley, a furgeon at Leeds, 
(who accompanied me in this viiit,) being in 
the neighbourhood of Linton, was confulted* 
He, entertaining hopes of removing the dif- 
eafe by internal remedies, did not recom- 
mend an operation, but advifed Mrs. Dean 
to take the Cicuta. 

The tumour had increafed very much within 
the laft fix weeks before my firft feeing it;; 
and, when I firft faw it, extended nearly, to 

the 



Fungus ILematodes. %55 

the axilla on one fide, and almoft to the 
fternum on the other. Its furface was uneven. 
The integuments were in general thick ; but 
not univerfally fo. In fome parts they felt 
rather thin ; and, upon preffmg thofe parts, 
it feemed as if the tumour contained a fluid. 
When I preffed the thick and harder parts of 
the tumour, I had the fenfation of fomethincr 
crackling beneath my ringers ; as if, by the 
preffure, I had broken fome fibrous fubftance. 
Shooting pains had been felt at times in the 
tumour from its commencement : they were 
now more frequent ; and Mrs. D. paffed the 
nights uneafily. She was languid, and her 
appetite was bad. 

I was apprehenfive that the tumour had 
arifen from the rupture of fome blood veffels, 
and that it would prove an untraceable dif- 
eafe. I thought it too late to attempt extir- 
pation : and, imagining that the integuments 
would foon give way, and that a confide rable 
haemorrhage might fupervene upon the burft- 
ing of the tumour, I informed my patient 
that I could not be of any fervice to her at 
the diftance of thirty miles ; and that it would 
be neceffary for her to come to Leeds, if fhe 
wilhed for my afiiftance. 

About a week after this viiit, Mrs. D. 



came 



25G FtTSdUS^ HiMATODES. 

came to Leeds, and put herfelf under tb6 
care of Mr. Prieftley and myfelf. Within ten 
days after her arrival me was feized with the 
dyfentery, which was then epidemic in the 
town* The affiftance of Dr. Davifon* a phy- 
fician in Leeds, was requefted, in the treat- 
ment of the dyfentery. During the eonti-* 
nuance of this difeafe, the fkin^ covering the 
tumour* gave way ; a dark-coloured fubftance 
arofe in the fiffure ; and blood began to ooze 
out from the aperture* at the bafe of this 
fubftance. 

The more I reflefited on the origin^ progrefs^ 
and appearance of the tumour, the more 
inclined I was to believe, that the difeafe was 
exafilly fimilar to that which had affefted the 
thigh of poor Campinet. I related this man's 
Cafe to Dr* Davifon, and Mr. Prieftley ; and 
expreffed my opinion, that Mrs* Dean's tu- 
tnour would be found to be of the fame 
nature* As the iituation of this tumoilr pre- 
cluded the advantage of applying a tourniquet^ 
I expefted that the haemorrhage would prove 
fatal, whenever a large opening mould be 
made* However* I did not choofe to with- 
hold my affiftance, how little foever that 
affiftance might avail > and confulted the gen- 
tlemen, who attended with me, upon the 

method 



Fungus JLematodes. 257 

method to be purfued, whenever the degree 
of haemorrhage fhould render it neceffary to 
make fome farther attempt to preferve the 
life of our patient. 

Auguft 1 9th, Mrs. Dean was nearly, but not 
entirely, free from her dyfenteric complaints, 
when the aperture in the tumour became fo 
large as to difcharge a confiderable quantity 
of blood. The orifice was now filled with a 
loofe plug of blood. When this was pufhed 
inwards, a great deal of extravafated blood, 
of a dark colour, rufhed out; partly fluid, 
and partly coagulated. 

I cut off a large oval portion of the difeafed 
integuments; with the defign, both of pre- 
venting the haemorrhage which they would 
have caufed, and of enabling me to apply the 
more readily, to the remaining part of the 
cavity, fuch ftyptics as we had determined to 
make ufe of. 

The fungous fubftance, which principally 
conftituted this tumour, had the fame appear- 
ance as that which I have defcribed in Cam- 
pinet's cafe ; and evidently bled upon being 
broken. It adhered ftrongly to the remain- 
ing part of the integuments, which formed 
a great number of irregular cells. Indeed, 
the whole internal furface of the fac contain- 



ing 



%5$ • Fungus H&matodes* 

ing this fungus was compofed of thefe cells; 
except the bottom, formed by the peroral 
mufcle, where the furface was more even. 
When the whole of the contained fungus 
was removed from the bottom of the fac* a 
portion of the pefitoral mufcle, about two 
inches fquare, was left uncovered. The muf- 
cle was in a morbid ftate ; and appeared as 
if it had been expofed to the air, and had 
begun to form granulations on its furface. 
The mufcular fibres were fcarcely diftinguifti- 
able. The whole internal furface of the fac 
bled uniformly, as if the blood had been 
fqueezed from a fpunge. To the mufcular 
part I applied Rufpini's ftyptic; and to the 
remainder of the cavity hot oil of turpentine. 
The cavity was gently filled with lint, dipped 
in thefe liquids ; and the applications were 
retained in their place by a circular bandage, 
put round the thorax. 

Notwithstanding our patient was kept in 
bed, m a horizontal pofition, during the 
operation, which I endeavoured to perform 
with all poffible expedition ; yet (lie fell into a 
deliquium before the dreffings could be ap- 
plied. She was, however, foon recruited, 
and fpoke to us cheerfully. We did not 
remove h^r in the leaft from her pofition ; 

but 



Fungus Hjematodes. 2159 

but made her as clean and comfortable s 
we could. We dire&ed that (he mould be' 
fupplied frequently with wine gruel, and other 
cordial nutriment of the moft grateful kind. 

At two o'clock in the night her pulfe ceafed 
to be diftinguiftiable ; and at eleven in the 
morning of the next day fhe expired. 

I did not obferve any unufual appearance 
of blood upon the bandages ; but Mrs. F. 
at whofe houfe me lodged, afterwards informed 
me, that (upon laying out the body) a good 
deal of blood was difcovered to have iffued 
from the cavity of the tumour* 

CASE III. ' 

In 1787> Mrs. Appleyard, a middle-aged 
woman, confulted me on account of a tumour 
in her breaft, which fhe apprehended to be 
of a cancerous nature* It occupied the whole 
mamma, was about the fize of a fmall melon, 
and was quite moveable* It had not the ap- 
pearance which cancerous tumours ufually 
have when they affeft the whole breaft. 
There was no puckering of the Qun, nor 
mrinking of the nipple ; but the integuments 
of the breaft had an uniform frnooth appear- 
ance. It had ftot, when examined by the 

s 2 touch, 



q60 Fungus ILematodes. 

touch, the uneven hardnefs of an occult 
cancer; neither had it the equal fbftnefs of a 
tumour containing a fluid in a fingle ■ cyfh 
Its furface was even; but, upon preffure, I 
could feel that" the contents of the tumour 
were not. of equal denfity- 

I afiured my patient that her diforder was 
not cancerous ; -but advifed the extirpation 
of the tumour, as it was highly improbable, 
that any internal remedies could check the 
growth of it. However, that I might not 
feem inattentive to her complaints, and at 
her earned requeft, I ordered fome medicines 
for her. A little time verified my prognoftic ; 
and in the courfe of two months after me 
firft confulted me, the tumour was fo muck 
increafed in bulk, that fhe confented to the 
operation which I had propofed. 

The operation was, however, delayed for a 
week, on account of a licknefs and frequent 
retching, which came on immediately after 
fhe had refolved to fubmit to this unpleafant, 
though often neceffary, method of cure. 
The uneafinefs of mind which me felt from 
the apprehenfion of an operation, feemed to 
be the fole caufe of thefe recent complaints. 
They were relieved by the ufe of aromatic 
and volatile medicines. 

Dec. 



Fungus JLematodes. 261 

Dec. 13 th. With the affiftance of Mr. 
Logan I extirpated the tumour, which 
weighed four pounds and three ounces avoir- 
dupois. It was perfectly diftincl from the 
furrounding adipofe membrane ; having no 
other connection with it than by that cel- 
lular membrane, which univerfally connefts 
the contiguous parts of the body. When 
divided by the knife, it had the appearance 
of a difeafed glandular fubftanee, intermixed 
with fmall cavities containing a gelatinous, 
or vifcid ferous, fluid. As the common in- 
teguments, which furrounded this morbid 
mafs, appeared to be in a found ftate, I 
placed them in conta6l with the fubjacent 
parts, applying plafters and bandage fo as to 
bring about a healing by the firft intention,. 

My patient went on extremely well for a 
time, and every circumftance flattered me 
with the hope of a fpeedy and happy termi- 
nation. At the end of the third week, when 
I was about to take my leave of her, a ferous 
difcharge began to take place from the loweft 
part of the wound, which was nearly, though 
not completely, cicatrized. After this had con* 
tinued fome days, I perceived a fmall ele- 
vation of the cicatrix a little above the part 
whence the ferous fluid iffued. The tume- 

s 3 fa&ion 



262 FUKGUS HiEMATOBES. 

fa6lion increafed gradually, till the cicatrix 
was burft open. A fubftance like dark 
coloured coagulated blood appeared in the 
fiffure. I was at firft inclined to think, that 
fome part of the integuments might have 
remained at a fmall diftance from the fubja- 
cent parts, with which I had endeavoured 
to unite them; and that the fmall veffels, 
.pouring out blood, might have caufed the 
tumefaction which I have mentioned. I intro- 
duced my finger at the fiffure ; and, finding 
a cavity extending an inch or two, under- 
neath the cicatrix, I divided the integuments 
at the cicatrix, and removed the coagulated 
blood, as it appeared to be. There was, 
however, a new formation of this fubftance : 
on which account I fprinkled the internal 
furface of the recent wound with finely pow- 
dered red precipitate ; that I might produce 
good granulations, and firm healing. My 
attempts were in vain. Inftead of an union 
of the parts, I obferved a daily growth of 
the fubftance, refembling coagulated blood, 
and an extended tumefaction under the ad- 
joining integuments, which' had been firmly 
united. There was now likewife a daily, 
though not a confiderable, haemorrhage from 
the cavity of the woun,d, 

*? ' Thefe 



Fungus Hjbmatodes. 263 

Thefe circumftances produced in me a 
painful conviction of the nature of this new 
difeafe ; and I could not doubt that it was 
fimilar to the complaint which I have de- 
fcribed in the two laft cafes. My patient at the 
fame time became much indifpofed, and was 
affecled with frequent ficknefs and retching, 
as me had been before the excifipn of her 
breaft. I informed her friends of the dan- 
gerous fituation in which me now was, and 
requefted a confutation. Mr. Lucas and 
Mr. Logan, furgeons to the General Infir- 
mary at Leeds, were called in : who con- 
curred with me in thinking that it was necef- 
fary to remove the difeafed parts, as the only 
means which could fave the life of our patient ; 
though the fuccefs of the operation was very 
doubtful. 

Feb. 7, 1788. With the affiftance of thefe 
gentlemen I performed the operation; mak- 
ing a large circular wound, and removing 
every part which had a morbid appearance. 
The fungus had funk into feveral cells, which 
were formed in the adipofe membrane ; and 
bled wherever I took hold of it. 

For a few days fhe feemed to be as well as 
we could expect. But a cough and difficulty 
cf breathing came on before the fymptomatic 

S 4 fever 



264 Fungus ELematodes. 

fever had ceafed : and flie (Jied on the feventh 
day after this fecond operation ; without any 
bad appearance in the wound, except fuch as 



extreme languor induces. 



CASE IV. 

Jan. 21ft, 1789, Mrs. StorrofYork, con- 
fulted me at Leeds, on account of a tumour 
in the left mamma. She was forty-five years 
of age, and had ceafed to menftruate for a 
year and half. She informed me, that 
about three months before, me had perceived 
a tumour nearly of the iize of a fmall apple. 
It had increafed confiderably in bulk ; efpe- 
cially fince the application of a plafter, which 
appeared to be the emplaJL litharg. cum 
gwnmi. She felt a conftant dull pain in the 
difeafed part ; but in no great degree. The 
fkin appeared rather red where the tumour 
was mofl; prominent The tumour was move- 
able, and felt hard in fome parts ; in others 
it gave the fenfation of a contained fluid. It 
was fituated on the exterior fide of the mamma. 
I recommended extirpation as the only 
probable method of cure ; and the next day, 
at her requeft, I performed the operation. 

The tumour adhered in part to the mamma., 
and had the appearance, when divided, of 

a clif- 



Fungus Hjematodes. 5265 

a difeafed glandular fubftance, interfperfed 
with three or four cyfts, containing a vifcid 
ferous fluid. The upper part of the wound, 
which was made in the adipofe membrane 
only, I united by two ftitches of the inter- 
rupted future. The lower part, in which a 
portion of the mamma had been divided, 
was united only by the help of flicking 
plafter. The upper part of the wound healed 
by the firft intention ; but the lower part was 
not completely healed till the expiration of 
eight weeks. 

One circumftance, which attended the 
healing of this wound, may defer ve to be 
mentioned ; as it afforded fome indication 
of that morbid ftate of the parts, which 
foon after produced a fatal difeafe. During 
the healing of the lower part of the wound, 
my patient complained of much forenefs and 
pain in the cicatrices of the upper part, par- 
ticularly thofe made by the punctures of the 
needles. Thefe were fo very tender, that for 
a time fee could fcarcely bear them to be 
touched. One of them burft open, and 
formed a fmall fore, which did not heal until 
I had rilled it with levigated red precipitate, 
This tendernefs did not come on immediately 
after the healing of the upper part of the 

wound, 



$66 Fungus Hjematodes. 

wound, but after the interval of two or 
three weeks. It was not attended with, any 
morbid appearance in the lower part of the 
wound. 

About fix weeks after the complete cicatri- 
zation of the wound, Mrs. S. began to feel a 
conftant uneafinefs in the part, and perceived 
it to be tumified. The tumefaction and un- 
eafinefs increafing, fhe .came again to Leeds, 
to put herfelf under my care. 

The tumefaction then extended about an 
inch and a half on each fide of the cicatrix. 
When it was examined by preffure, there 
was a fenfation of a deep feated fluid, covered 
by thick integuments. The fikin, in its moft 
prominent parts, had a blue appearance. 

I fufpected that the difeafe, which I have 
defcribed in the three preceding cafes, had 
taken place : and I defired a confutation. 
Mr. Lucas vifited the patient with me; and, 
as we could prppofe no probable means of 
cure but a fecond operation, with his affifV 
ance I extirpated the tumid parts, which 
contained a fubftance fimilar to that defcribed 
in the preceding cafes, No part of the inte- 
guments was left that had the leaft morbid 
appearance; and the difeafe feemed to be 
completely removed. 



Fungus Hematodes. 267 

The wound was foon filled with good gra- 
nulations, and the cure proceeded in the 
moft favourable manner for about three weeks. 
A fnrall portion of the wound at its upper 
part then began to look floughy, and formed 
a cavity extending about an inch under the 
adjoining integuments. I filled this part 

A 

with Hydrar. nitrat. ruber j; but a fubftance 
like dark-coloured coagulum of blood arofe 
in it, the growth of which was not repreffed 
by the efcharotic. I thought it beft to remove 
this morbid part ; and, having divided the in- 
teguments about an inch and a half, I diflected 
out all that appeared to be difeafed. 

The appearance of the fore continued 
favourable for fome time after the removal 
of this morbid part ; and the progrefs of 
healing was as fpeedy as is ufual in fores of 
fuch extent. But, before the cicatrization 
was completed, the parts which had been 
healed, and the contiguous integuments, 
began to grow tumid, and to mew too clearly, 
that the morbid fungus, which had made 
a fec'ond operation neceffary, was forming 
again. 

My hopes of a cure were now entirely 
deftroyed. As every part, which had the 
leaft appearance of difeafe 5 had been twice 

removed, 



268 Fungus H&matodes. 

removed, I faw no probability that any 
farther furgical affiftance could fave the life 
of my patient. She returned home in the 
beginning of Auguft, and died at the end of 
five weeks after fhe left Leeds, 

CASE V. 

A boy about fourteen years old, was ad- 
mitted an in-patient of the General Infirmary, 
on account of a large deep-feated tumour in 
the calf of his leg. The caufe of this diforder 
be judged to have been a fprain, from a fud- 
den and violent exertion; for, foon after this 
accident, he perceived the calf of the difeafed 
leg to be larger than the other. The tumour 
had continued to increafe during fix months, 
and he w r as now rendered very lame by it. 

It w r as impoffible to afcertain, with preci- 
iion, either the fituation or nature of this 
tumour. It was clearly fituated behind the 
gaftrocnemius mufcle, and might have its 
origin near the bones of the leg ; fo that an 
attempt to extirpate it by incifion, was out 
of the queftion. There was no pulfation in 
the tumour, nor any difcolouration in the 
integuments. The accident which had pre-? 
ceded the appearance of this tumour rather. 

indicated, 



Fungus Hematodes. 269 

indicated, that it had arifen from the rupture 
of fome veffels in the leg. 

Upon a confutation, no probable method 
of cure was fuggefted but that of amputation ; 
and, the parents of the boy giving their 
confent, I performed the operation above 
the knee. 

After the operation I differed the leg, and 
found the tumour to confift of a fubftance 
fimilar to that which I have defcribed in the 
preceding cafes, fituated between the gastroc- 
nemius and folaeus mufcles^ and extending a 
little below their edge on the outer fide of the 
leg. Wherever this fubftance lay in conta6t 
with the mufcular fibres, they were of a 
brown colour, and had loft their ufual diftincl 
appearance. We could perceive no ruptured 
veflel; but the lymphatics were not injecled* 

The patient had a good recovery. 

CASE VL 

In April 1793, I vifitedMr. Thomas Ward 
of Saxton, near Tadcafter, aged thirty-three 
years, who had a large tumour near the ancle 
of one leg, the circumference of which, in- 
cluding the leg, meafured twenty-one in- 
ches. The account which he gave me of the 

origin 



£70 FUSFGUS HjfcMATODES. 

origin and progrefs of this tumour, was as 
follows : 

Four years ago, laft winter, foon after he 
had walked out in the morning, he felt fome 
pain in his heel ; and from that time he could 
not, without pain, put the heel to the ground 
in walking. Some months after this attack, 
he perceived, juft below the ancle, a fmall 
tumour, about the lize of a horfe-bean, which 
was moveable, but not painful. This tumour 
continued to increafe in bulk gradually, and 
was for fome time unattended with pain. After 
fowing fome corn in the fpring following the 
firft appearance of this tumour, in which 
exercife he imagined he had hurt himfelf, 
the tumour began to increafe more rapidly, 
and was then attended with pain, and an 
increasing weaknefs of the leg. 

In May 1792, the tumour and weaknefs 
had fo far increafed, that he was but juft 
able to walk afyout, with the affiftance of a 
walking ftick. At this time he put himfelf 
under the care of a perfon, who applied 
bliftering plafter to the tumour, and rubbed 
it fomewhat feverely with tow, when the 
cuticle was removed. Under this treatment, 
the fize of the tumour, and the weaknefs of 
the ancle, were fo much increafed, that he; 

was 



Fungus Hjematodes. 271 

was in a few days unable to walk without 
crutches. 

About a week before I faw this patient, 
the tumour had been punfihired with a 
lancet b}^ an old woman, under whofe care 
he had placed himfelf. A dark coloured fun- 
gus, refembling coagulated blood, had arifen 
from the wound, and was in breadth nearly 
equal to that of a half crown. 

The fenfation which the tumour afforded, 
when examined by gentle preffure, compared 
with its contents, which were become evident 
by the wound made in it, left no doubt in 
my mind refpe&ing the nature of the difeafe, 
and the remedy which alone could prove 
curative. 

The mind of my patient revolted at firft 
at the idea of amputation ; but in the courfe 
of a few days, he became fully fenfible of the 
neceffily of this operation, which I performed 
the following week, but not before he was 
much reduced by the lofs of blood from the 
fungus. 

I was obliged to take up fifteen arteries, 
after amputating -the leg, a little below the 
calf. The fungus, when divided, appeared va- 
riegated like a nutmeg, fome parts appearing 
red, like blood, while others were almoft white. 

It 



%72 Fungus I-Lematqdes. 

It felt greafy when handled. The patient re-* 
covered, and continues healthy. 

CASE VIL 

In November 1796, Mr. Wright, of 
Horsforth, confulted me on account of a 
large tumour, fituated in the neck of his fon, 
who was about nine years of age ; and gave 
jne the following account of the difeafe : 

In April preceding, the little boy happened 
to fall againft the poll of a gate. The ftroke 
affe&ed chiefly the lower jaw on one fide, 
and loofened four of the grinders, but made 
no wound. The bruife appeared to be incon- 
fiderable, and was not expected to produce 
any unpleafant confequences. Towards the 
end of the month, the part which had been 
ilruck, began to fwell gently ; and the fwel- 
ling had a gradual, though flow, increafe. In 
Auguft, the fwelling had .grown to the fize 
of a fmall hen's egg. In this ftate, a poultice 
was applied to the part affected, which feemed 
to increafe the growth of the tumour, and 
to render the Ikin fomewhat reel. 

When I was confulted in November, the 
tumour was about nine inches in length, and 
fix or feven in breadth. It extended from 

the 



Fungus Hjematodes. 273 

the lower jaw to the clavicle* From the ap- 
pearance, and the fenfation felt on examining 
the tumour by gentle preffure, I judged this 
to be a cafe of the Fungus Hcematodes. I 
informed the boy's parents of the incurable 
nature of the difeafe, and prognofticated the 
fpeedy approach of the fatal event, which 
took place about ten days after I had feen 
this patient. The boy's father afterwards 
informed me, that the tumour feemed to 
produce fuffocation by its preffure upon the 
windpipe. 

CASE VIII. 

Richard Finney, the driver of a ftage 
waggon, confulted me in January 1797, on 
account of a tumour in the back part of his 
neck, which had been formed in that part 
about two years, in confequence of a hurt 
which he had received. I punftured the 
tumour with a lancet, that I might difcover 
what was the nature of its contents, and 
found nothing in it but coagulated blood. I 
brought the lips, of the punfture into conta6t 
by plafter, that I might produce an adhelion, 
and immediate healing of the vround r in- 
tending to lay open the tumour at a more 

T convenient 



%7% FUSTGTJS HiEMATODES. 

convenient opportunity. I defired the mail 
to reft from labour till the puncture fhould 
be healed. He neglected this advice, and 
fet off foon after with his waggon. He was* 
much expofed to the eold air, the weather 
being then fevere; and an inflammation of 
the tumour foon fupervened. The fever which 
attended this inflammation confined him 
upon the road for a time; but he was brought 
back to Leeds about a fortnight after I hud 
punctured trie part. The inflammation , ftill 
continued; but with proper care fubfided,' 
and the contents of the tumour were in part 
difcharged. That I might produce a com- 
plete evacuation of the contents without 
making any large wound in the neck, which 
now feemed unneceflary, I introduced a fetoia 
firing, and made it pais through the tumour 
near its bafe. By this treatment the tumour 
feemed to be completely emptied , and gra- 
dually difappeared". I then withdrew the 
firing, and the punctures healed. 

In the courfe of a few weeks, a finall tu- 
mour arofe in the fame part, which was 
evidently owing to the dilatation of the origi- 
nal fac by fome fluid. Upon puncturing the 
fac, a fluid of a glairy kind, without colour, 
iffiied out, Having reaped fo much benefit 

from 



FulSTGUS ELfcMATODES. 275 

from the ufe of the feton before, I made ano- 
ther through the cyft in the fame manner, 
hoping to bring about an adhefion of the 
fides of the cyft. My expectation, however 
proved abortive. Inftead of a gradual con- 
traction of the cyft as after the former opera- 
tion, the tumour in a Ihort time began to 
increafe, and a difcharge of blood took place 
from fome fiffures in the diftended integu- 
ments. 

May 27th. I opened the tumour in its whole 
extent, and removed a fungus, which was now 
formed in it, excepting a part which adhered fo 
ftrongly to the mufcles of the neck, that I could 
not clearly diftinguifh it from the mufcular 
fibres. The haemorrhage was profufe, and on 
this account alfo I was compelled to deiift be- 
fore I had removed the whole of the fungus. 
The man was fo foon recruited after this 
operation, that on the 6th of June, he was 
able to come to my furgery to be drefled. 
After repeated fprinkling withHydrar. nitrat. 
rub. the wound put on a favourable afpecl. 
Healthy granulations arofe from the furface, 
and the ulcer became much contracted in 
its fize. I entertained now great hopes of 
a complete cure; but after fome weeks 5 
the morbid fundus began to form itfelf at 

T 2 the 



276 Fungus. IIematodes. 

the edges of the fore. The integuments 
were divided where the fungus had elevated 
them from the fubjacent mufcles, and the 
morbid part was fprinkled with efcharotics- ' 
of various kinds. The fungus was reproduced 
fader than I could deftroy it, and the poor 
man became languid under the increafe of this 
obitinate difeafe. In November he was ad- 
mitted a patient of the General Infirmary, 
and there I once more differed out the fun- 
gus, now become confide rably larger. The 
haemorrhage was great; but he recovered,; 
and the furface of the wound once more, for 
fome time, put on a favourable appearance* 
My hopes were again difappointed, and the 
■fungus became larger than ever. Almoft 
every kind of efcharotic was tried, but in 
vain. I could not reprefs the growth of the 
fungus by the undiluted vitriolic acid, by the 
Hydrargyras muriatus, Antimonium rnuria- 
turn, nor any other application that was ufexL. 
In the fp ring 1798, the man left the Infir- 
mary; a cough fbpervened, and he died the 
10 th of June following, exhaufted byahe£fcic 
fever, and a copious difcharge of fetid matter 
from the fungus, which was then confider- 
ably increafed in fize. 

Auguft 



Fungus PLematodes. 277 

CASE IX. 

Auguft 20th, 1801, James Richardfon, a 
flout man, aged fifty years, confulted me on ac- 
count of a large tumour on the pofterior part 
of his left moulder. Upon a careful exami- 
nation I could not doubt of its being a tumour 
of that intra6table fpecies, to \diich I have 
given the name of Fungus H&matodes. 

As the knowledge of this difeafe in its in- 
cipient ftate may be of importance, I will 
give a defcription of this cafe; which I ap- 
prehend will not be found inapplicable to the 
general appearance of the difeafe, when it 
arifes fpontaneouiTy, without any previous 
operation, 'upon a part not endued with great 
fenfibility. 

TAe tumour was not painful. It had 
arifen to a confiderable fize before the patient 
was aware of its exiftence ; and it was firft 
pointed out to him by his friends, who ob- 
ferved, that the pofterior part of one moulder 
was become larger than the other. 

It did not interrupt the motion of the 
mufcles upon which it was lituated; the 
patient being able, as he informed me, to 
follow his laborious employment of a black- 
finith as well as ufual. 

T 3 Its 



%7& FtTJffGUS BL&MATODES. 

Its fituation feemed to be between the 
integuments and external mufcles, a little 
below the joint of the fhoulder, covering a 
great part of the fcapula. 

Its form and fize may be underftood by 
the following meafurement, which I took 
with a marked tape : from the bafe on one 
fide, to that on the oppofite fide, where the 
breadth was the greateft, carrying the mea- 
fure over the fummit of the tumour, it mea- 
fured 12 inches. The meafure taken acrofs 
the tumour, in the fame way, at its fmalleft 
breadth, was 8 inches. Its bafe tneafured 
<23 inches. 

When examined by gentle preffu|re in va- 
rious ways, it feemed to be of M uneven 
denfity. In fonie parts an alternate .preffure 
gave the fenfation of a deep feated fluid* 
When grafped by the fingers in other parts, 
one might perceive an irregular hardnefs. 
This examination gave no pain. 

It was moveable, but in a flight degree : 
not fo much as a wen formed by an enlarge- 
ment of the adipofe membrane. 

The cutaneous veins, which ran over its 
furface, were enlarged. 

Some idea of its growth may be obtained 

from the following particulars. It was firft 

3 examined 



Fungus H^matodes. 279 

examined in July 1 800, and it was then judged 
to be about half the size at which I found 
it. The patient had been lately at Harrow- 
gate, and had ufed a hot bath there, which 
he apprehended had much increafed tha 
lize of the tumour. 

The integuments did not feem to be ren- 
dered thinner by the diftention of the fungus, 
which I conceived to be lodged beneath and 
within them. 

The flun had been irritated by fome ftimu- 
lating applications which had been made to it. 
I directed the application of the Cerat. Lap. 
Calam. to remove this fuperficial inflamma- 
tion ; and advifed the poor man to do nothing 
elfe, as I conceived the difeafe to be incur- 
able. 

I mewed this Cafe to Mr. Logan, my 
colleague at the General Infirmary, who con- 
curred with me in opinion, refpefting the 
nature of the complaint, and the impropriety 
£>f extirpation. 

I faw this patient again in February 1802, 
and was informed by him, that he had been 
under the care of fome irregular practitioners, 
fuppofed to be fkilful in the cure of cancers. 
The tumour was much enlarged, and begin- 

T 4 ning 



280 Fungus Hjematodes* 

ning to ulcerate. His countenance.was fallen^ 
and his ftrength feemed to be declining. 

CASE X. 

Ann Wood, aged 30 years, was admitted an 
in-patient of the General Infirmary, in Febru- 
ary 1802, under the care of Mr. Logan, on 
account of a large tumour at the extremity 
of the fore-arm near the wrift ; and gave the 
following account of her cafe : 

About ten months before her admiffion§ 
{he began to feel pain in the wrift of her arm, 
attended with great weaknefs, but no fenfible 
tumefaction of the part. About two months 
after this attack, (he perceived a fmall. tumour, 
near the end of the radius, about the fize of 
a marble, which gradually increafed in bulk* 
About five months before her admiffion, a 
feton had been put through the tumour by a 
furgeon whom (he then confulted. After this, 
the tumour grew more rapidly, and by de- 
grees an excoriation took place in fome parts 
of the tumour, which were more prominent 
than the reft. Three months before her ad- 
miffion, a haemorrhage took place from one 
ofthefe excoriated parts, at which time me loft 
about eight ounces of blood. The tumour had 

bled 



Fungus Hjematodes. 281 

bled repeatedly fince that time, but never to 
fo great a quantity at once. 

Mr. Logan called a confultation of the 
furgeons of the Infirmary, at which it was 
determined to amputate the arm below the 
elbow, as the parts above the tumour appeared 
to be in a found ftate. The tumour was 
not meafured, but it was ^bout tjie iize of a 
moderate melon. 

When divided after amputation, the con- 
tents were of an a(h-colour, though fomewhat 
variegated. To the touch they felt greaiy, 
like the brain. A part of the radius, at its 
inferior extremity, about two inches in length, 
was wanting;. The ulna was whole, and re- 
mained covered with its periofteum, though 
the tumour lay in contact with it. 

The integuments were kept in contact by 
means of the interrupted future, and the 
wound was completely healed on the 13th 
day after amputation. 

When I confider that this difeafe had fub- 
fifted two months, cauling pain and weaknefs 
in the arm, before any tumefaction was per- 
ceived by the patient; that the tumefaction 
was of fmall extent at its firft appearance ; that 
the periofteum and bone had been deftroyed 
by the difeafe in that part where it had com- 
menced; 



%82 Fungus Bjematodes, 

menced; and that neither the bane nor the 
periofteum of the ulna appeared to be injured 
by it, though the fungus lay evidently in 
contact with the latter; I am inclined to think, 
that the difeafe, in this eafe, originated in 
the bone, or at leaft within the periofteum. 
It deferves to be conlidered, whether in a 
fimilar cafe, it would not be the beft practice 
to open the tumour at its firft appearance. 
This feemsto be the only method of prevent- 
ing the dreadful ravages, which we fee this 
difeafe is capable of making, when left to it^ 
felf. But I am far from being fanguine, that 
even this method, together with the removal 
of what might appear morbid within the tu- 
mour when opened, would effectually prevent 
the growth of this obftinate fungus. 

I have now feen fixteen or feventeen cafes 
of this difeafe, and perhaps many more, when 
I was not fufficiently aware of its nature, and 
have not been able to efFe6l a cure in any in- 
ftance, but by amputation of the limb, when 
the feat of the difeafe was in the extremities, 
A few years ago, I amputated the arm of a 
middle aged man below the elbow, who had 
vl tumour exactly fimilar to that laft defcribed, 
but the ftate of the bone was not examined, 
nor d|d I examine it in the cafe of Mr. Ward 

(Cafe 



Fungus Hjematodes. 283 

(Cafe VI.) having feen no affection of the 
bone from it at that time. 

If I do not miftake, this difeafe not unfre- 
quently affects the globe of the eye, caufing 
an enlargement of it, with the deftruftion of 
its internal organization. If the eye is not 
extirpated, the fclerotis burfts at the laft; 
a bloody famous matter is difcharged, and the 
patient links under the complaint. 

When the difeafe occupies merely the adi- 
pofe or cellular membrane lying upon the 
furface of the mufcles ? the tumour is not 
ufually painful in its beginning, nor does it 
impede the motion of the mufcles on which & 
is feated. But when deep feated in the limbs, 
it caufes pain and weaknefs of the part affect- 
ed. Mrs. Dean found considerable pain from 
the growth of the tumour in the mamma. 

The fungus, as it increafes in bulk, does not 
render the integuments uniformly thin, as in 
the cafe of an abfcefs. In one part the 
tumour, when preffed with the hands, will 
afford the fenfation of a deep feated fluid, 
while another part feels hard and uneven. 
In Mrs. Dean's cafe, there was a fenfation as 
if fome fibres were broken, when the tumour 
was handled with preffure. 

In an advanced ftage of the difeafe, the in- 

teguments f 



&84 Fungus Hj&matodes. 

teguments, and aponeurofis of the mufcles, 
(if the fungus is fituatecl beneath this part) are 
bur ft open, and the fungus which rifes through 
the aperture fome times appears black, like a 
mafs of coagulated blood. At other times 
the appearance more refembles an excoriation. 
Under both thefe circumftances haemorrhages 
enfue. 

In this procefs, the integuments do not be- 
come uniformly thin, and of a red colour, as 
when purulent matter is making its way; but 
they continue to feel thick as ufual round the 
fungus that has burft through them. 

This fungus is an organized mafs, and 
bleeds wherever it is broken. 

When the parts containing the fungus are 
divided, they are found to be in a morbid 
ftate. The adipofe membrane forms a great 
number of pouches, filled with the fungus, 
upon the removal of which the pouches bleed 
copioufly, from every part of their internal 
furface. 

Wherever the fungus comes into contact 
with the mufcles, they lofe their natural red- 
nefs, and become brown. They alio lofe' 
their fibrous appearance, and cannot in every 
part be diftinguifhed from the adipofe mem- 
brane* 



T<> A'(/-<- l J /"/r 283. 



PL .% 




Fungus Hjematodes. qss 

brane, though a diftinction is in general 
evident. 

The growth of this fungus cannot always 
be repreffed by the ftrongeft efcharotics. 
Neither the hydrargyria nitratus ruber, the 
hydrar. muriatus, the antimon. muriatum, nor 
the undiluted vitriolic acid, have been fuffi- 
cient for this purpofe. 

The annexed plate was engraved from a re- 
duced copy of a drawing, which Mr. Logan 
had procured to be taken from one of his 
patients in the Leeds Infirmary, afflicted with 
the Fungus hoematodes upon his arm. The 
circumference of the tumour, including the 
arm, meafured thirty-three inches. The iitua- 
tion of the tumour rendered {imputation im- 
practicable, and the difeaie of confequence 
proved fatal. 



"Sac 



[286 ] 

CHAP. V, 

On Dislocations, 



THOUGH the reduaion of diflocated 
bones is not ranked amongft the moft difficult 
operations of furgery; yet cafes fometimes 
occur in which an experienced Surgeon may 
find reduction to be an arduous tafk, or may 
even be foiled in the attempt. A few obfer^ 
vations on this branch of furgical practice, 
may not, therefore, be unacceptable to the 
young practitioner. 

The di/locution of the o$ humeri at the 
fhoulder, is the moft frequent fpecies of 
diflocation, which calls for the aid of the 
Surgeon. 

Before the reduction is attempted, that 
part of the arm to which the extending power 
is to be applied, ihould be well defended with 
fome foft fubftance, otherwife the patient feels 
much unneceffary pain in the operation. Soft 
leather, quilted with wool, forms a convenient 
defence ; but I generally make ufe of a long 
flannel roller, as being the moft readily ob- 
tained* 



On* Dislocations. 287 

tained, with which I cover the lower part of 
the arm, and upper part of the fore-arm. 

Mr. Lucas, when he was my colleague at 
the General Infirmary at Leeds, (Viewed me 
a method of applying a towel for the purpofe 
of extenfion, which is the mod convenient that 
I have feen; but the defcription upon paper 
is fomewhat difficult. 

Take a piece of linen or callico, about 
three yards in length, and half a yard in 
breadth; fold this longitudinally till it is 
reduced to about three inches in breadth ^ 
then place its middle part in an elliptical 
form, as in Plate VIII. figure 2, and put (^ 
the elliptical part round the limb, till the 
parts h. L come nearly into contafii with 
each other. Then put the tail f 9 through 
the noofe at z, and the tail g, through the 
oppofite end of the noofe at A, by which means 
the elliptical part mull be drawn tight round 
the limb, and the tails of this bandage muft 
be ufed as the means of extenfion. 

If the head of the os humeri remains in the 
axilla, and not far removed from the glenoid 
cavity, the reduction may fometimes be ex- 
ecuted with a very fmall degree of extenfion, 
as in the following cafes, 

CASE 



£88 On Dislocations.* 

C'A S E I. 

In the fummer 1772, a corpulent womaii 
fell from a chair, on which fhe was {landing* 
for the purpofe of hanging up fome linen to 
dry, and diflocated her moulder.. After I had 
put every thing in proper order for the reduc- 
tion, I defired the affiftants, who were to make 
the extenfion, to keep the arm elevated at a 
right-angle with the body> till I mould direft 
them to begin the extenfion* In doing this, they 
kept the arm a little upon the ftretch, waiting 
for my orders. While the arm was in thisftate 5 
I placed my fingers below the head of the bone* 
that I might be ready to co-operate with 
them; and preffing my fingers upwards into 
the axilla, that I might feel the head of the 
bone diftinctly, the reduction was unexpect- 
edly made by this gentle effort. 

The refult of this cafe determined me to 
try, whether reduction might not fometimes 
be effected with lefs extenfion than is com- 
monly ufed, and confequently with lefs pain 
to the patient than is generally experienced* 

It appeared to me, upon reflection, that the 
mufcles, when fo far ftretched as to be ren- 
dered painful, begin to re-a6f, and to refift 



On Dislocations. 289 

the efforts made for their farther elongation, 
I though tit probable, therefore, that a greater 
degree of exteniion might be produced before 
the ' re-action took place, if the extenfion 
were made very {lowly; and that the re- 
action might grow lefs, or even ceafe, after it 
had begun to take place, if the arm were 
kept in a moderate, but not painful,, degree 
of extenfion for fome time, before any attempt 
was made to pufli up the head of the bone 
into its articular cavity. By a£ting upon this 
principle, I have feveral times reduced a 
luxated os humeri, with the afliftance of'veiy 
little extenfion. I cannot fay that this me- 
thod has always fucceeded, but it certainly 
deferves to be tried; and I am inclined to 
think, that much extenfion is felclom necefiary 
when the head of the bone remains in the 
axilla. In all cafes, the more flowly the ex- 
tenfion is made, the more will the refiftance of 
the mufcles be eluded; the probability of. 
fuccefs will be increafed, and the patient will 
not fuller anv degree of unneceffarv oain. 

CASE II. 

In January, 1 773, an elderly man diflocated 
the os humeri at the fhoulder, by falling from 

U a plank 



290 On Dislocations. 

a plank which ferved as a bridge to a ditch. 
After I had faftened the towels upon the arm, 
and given directions to the affiftants, I ex- 
amined the fituation of the head of the bone 
in the axilla, before I gave them orders to 
begin the extension. They put the arm, how- 
ever, a little upon the flretch in holding it by 
the towels ; and the gentle preffure which I 
made in feeling for the head of the bone pro- 
duced the reduction. 

I once faw a luxated moulder reduced bv 
the mere efforts of the patient. 

CASE III. 

In May, 1774, I was called to an elderly man 
who had diflocated his moulder by falling as 
he was walking. He was very uneafy while 
I was making the neceilary preparations, after 
I had afcertained the exiftence of the difeafe. 
He walked about the room, putting his arm 
into various pofitions, to procure a little 
eafe. With this view he placed his hand upon 
the back of a low chair, and moving his body 
in different directions, he fuddenly cried out, 
as if hurt more than ufual. He then fat down, 
and faid, that he was eafv, and could move 
his arm better. As foon as my apparatus 

was- 



Otf Dislocations. 291 

was ready, and I had taken hold of his arm 
for the purpofe of fixing the towels, I was 
furprifed to find that the os humeri was re- 
duced. There was now a natural roundnefs 
in the moulder below the acromion, though 
before a hollow was felt upon preffing the 
deltoid mufcle. His elbow, which before 
flood at a diftance from his body, could now 
be preffed to his fide with eafe* 

When the head of the bone has deferted 
the axilla, and has flipped under the pectoral 
mufcle, I have obferved, that it is brought 
back into the axilla the more readily, if the 
exteimon is made in a direction oppofite to 
that in which it has paffed from the axilla* 
This effect is often greatly promoted by mak- 
ing the extenlion w r ith the arm elevated, as 
Mr. White has advifed. But when the head of 
the bone has advanced far under the pectoral 
mufcle, llrong extenlion* by clofing the paf- 
fage through which the protuberant part of 
the bone mould return, often prevents, inftead 
of promoting, reduction. A more fuccefsful 
method of managing thefe cafes will be men- 
tioned in the fequel. 

The following inftances of difficult reduction 

may afford fome inftruction and encourage- 

meat to the young practitioner* 

U 2 CASE 



292 On Dislocation*. 

case IV. 

In October, 1 773, a itout man was brought 
into the Infirmary, with a luxation of the 
{boulder-joint. The head of the os brachii 
lay deep under the coraeoid procefs of the 
fcapula. I firft tried the method which I had 
moil commonly ufed in this cafe, which was- 
as follows : the body being fupported, and 
a counter extenfion made, by means of a 
broad towel put round the thorax of the 
patient, the extenfion of the arm was made by 
three or four men, firft in a direction at right 
angles to the body, and when the extenfion 
was in its greateft degree, by pulling the arm 
towards the ground at an acute angle to the 
body, while I attempted to raife the head of 
the bone by my hands, placed as near it as I 
could. This method failed ; fo did that with 
the heel in the axilla. I then drew up the 
man a little from the ground by means of 
vertical pullies, and by this extenfion the head 
of the bone was brought into the axilla, fa 
that it could be readily felt through the in- 
teguments, but could not be pufhed into the 
articular cavity. I repeated the method firft 
tried, but in vain. I fuceeeded at laft by the 
H following 



On Dislocations. 253 

following method, which is nearly that recom- 
mended by Dr. Kirkland*: 

I placed my patient on a cufhion upon the 
ground, and put a towel under his arm near 
the {houlder, which went over my ihoulders. 
His arm was put betwixt my thighs; and the 
affiftants, who fat on the floor behind me, 
made the extenfion with towels affixed to the 
arm and fore-arm. 

When the extenfion was made to the de^- 
gree which 1 judged neceffary, I raifed up 
the head of the os brachii by means of the 
tow r el which was fufpended upon my (boul- 
der^ and at the fame time depreffed the 
other end of the bone, by placing my hands 
upon it. By this method the reduction w 7 as 
effected. 

CASE V. 

September 22d, 1774, I was called upon. 

early in the morning to vifit Thomas Walker, 

of Woodlesford, a ftrong mufcular man, and 

a ftone-mafon by trade, who had been thrown 

from his horfe the preceding evening, and had 

been dragged for a hundred yards or upwards 

■ 

Obfervations upon Mr. Pott's general Remarks 
on Fraaures, &*c. p. 60. 

u 3 by 



294 On" Dislocations. 

by his foot hanging in the ftirrup. His left 
arm was diflocated at the flioulder, and the 
head of the bone was lodged deep in the 
axilla, beneath the coracoid procefs of the 
fcapula. 

I firft tried to reduce the bone by Dr. 
KirklancVs method, but in vain. I then 
dire&ed the extenfion to be made in a vertical 
pofition of the arm, as Mr. White advife$* 9 
until the patient was raifed from the ground, 
and immediately tried to reduce the bone 
with the heel in the armpit, but to no pur- 
pofe. I made feveral other attempts, making 
the extenfion fometimes with the fore-arm, at 
right angles to the os humeri, fometimes 
with the whole arm extended, varying alfo 
the direction of the extenfion. All my at? 
tempts were ineffectual. I defired my patient 
to come to Leeds, that I might have the 
advantage of a pully, and the affiftance of 
my colleagues at the Infirmary. About 
eight ounces of blood had been taken from 
the arm before I was called. I direfted a 
repetition of the bleeding, and the ufe of the 
warm bath, as foon as he mould arrive at 
Leeds. I called a confutation at three ix* 

# Cafes in Surgery, 95; or Med, Obfervations and 
Inquiries, vol. £, 373. 



y 



X)n Dislocations, 295 

the afternoon, and was favoured with the 
afiiftance of Meffrs, Billam, Jones, and Lucas, 
at the Infirmary. 

The blood had been drawn as I directed, but 
he had not been put into the warm bath. 

Our firft trial was made by railing the 
patient from the ground by a cord, paffing 
over two vertical pullies, and fattened to the 
arm above the elbow by fuitable ftraps. I 
tried to puili the head of the bone into its, 
focket while he remained in this ftate of fuf- 
peniion, but I could not effect it. Mr. Bil- 
lam tried with his heel in the armpit, having 
a clue of cotton previoufly placed in the 
axilla: upon this clue was put the middle 
part of a long towel, the extremities of which 
I took hold of, lying upon the ground, with 
my foot placed upon the acromion fcapulse, 
When Mr. Billam made his extension, I 
affified by a counter extenfion, pufhing down- 
wards the acromion,, and elevating the head 
of the os humeri. This attempt alfo proved 
fruitlefs. We then repeated the fufp.enfion, 
intending to ufe Dr. Kir- land's method as 
foon as he mould be let down. As we were 
removing the ftraps from his arm, Mr. Jones 
fuggefted the idea of letting his arm fall down, 
without an v farther extenfion. This was done 

u 4 in 



296 On Dislocations. 

in a gentle manner, but fo that the arm fell 
by its own weight.* In this motion, the head 
of the bone flipped into its locket,, but I did 
not perceive any jerk or found as is ufual in 
the reduction of diflocated bones. As a good 
deal of force had been ufed in this cafe, it 
was thought prudent to take four ounces 
more of blood from him. He flept well that 
night, and the next day was pretty eafy. 

CASE VI. 

September 22d> 1775, a middle-aged man 
from Aldborough near Boroughbridge, was 
admitted a patient of the General Infirmary, 
on account of a diflocation of the os humeri, 
at the moulder, which had happened a month 
before his admiffion. The head of the bone 
lay behind the thick part of the pectoral 
mufcle, arid below the coracoid procefs of 
the fcapula. Some attempts had been made 
to reduce the bone immediately after the 
accident, but without fuccefs. 

After he had lain ha the warm bath about 
twenty minutes, the following methods were 
tiled to effect the reduction: After the arm. 
was properly defended, ftraps, to which cords 
were affixed, v/ere fattened by buckles, upon 

the 



On Dislocations. 297 

the lower part, and he was drawn up gently 
from the ground by the help of pullies. Re- 
peated trials by this method produced no 
fenfible effect. We then ufed Freke's im- 
proved Ambi, and at one trial the bone fud- 
denly advanced as if a reduction had taken 
place; but repeated efforts in this method 
had not the defired effect. We next made 
ufe of the methods recommended by Dr. 
Kirkland and Mr. White, placing a towel 
round the operator's neck, and holding back 
the inferior part of the fcapula by means of 
a roller covered with cloths. Mr. Lucas and 
Mr. Jones afterwards tried to reduce the 
bonebv the heel in the axilla, and Mr. Lucas 
perceived a noife during one effort, as if the 
bone had returned to its place. While the 
laft method was in ufe, it occurred to me, 
that extenfion made in a direction parallel 
to that of the body was not likely to fucceed, 
while the head of the bone lay fo deeply 
funk, and behind the peftoral mufcle. I 
therefore advifed, that one perfon mould 
extend the arm at right angles to the body, 
by the hold of the fore-arm, placing his foot 
againft the fide of the patient's thorax. In 
this way, the perfon making the extenfion 
would not only have a firm fupport, but 

would 



£9S Ox Dislocations. 

would alfo be enabled to reprefs the lower 
part of the fcapula by his heel placed againft 
it. That daring this extenfion, another per- 
ton, lying by the fide of the patient, fhould 
place his heel againft the upper part of the 
os humeri, as near to its head as poffible, 
and fhould pulh it in a direction parallel to 
that of the patient's body. By this method, 
the bone altered its fituation with fuch a 
noife as is ufually heard in reductions, and 
we concluded, that the head of the bono 
had re-entered the focket; but when the arm 
was brought clofe to the patient's fide, we 
found that the head of the bone was ftill in 
the axilla. This appearance of fuccefs en- 
couraged us, however, to repeat the opera^ 
. tion, but the event was the fame. We now 
imagined, that fome portion of the capfular 
ligament might be folded fo as to be inters 
cepted between the head of the bone and the 
glenoid cavity, into which we judged the 
bone to have been twite brought. On this 
fuppofition, after making the reduction the 
third time, the os humeri was moved in 
various directions, fometimes upon its own 
axis, fometimes upwards and downwards, 
^ ; ; before we attempted to bring the arm towards 
the patient's fide. Alfo, while the extenfion 

was 



On Dislocations. 299 

was continued, a flattened ball of tow was 
thruft up into the axilla by the heel, to 
prevent the head of the bone from retiring 
again into the axilla ; the arm was then 
brought into contact with the patient's fide, 
the extenfion being continued, though in a 
different direction, and the heel being gra- 
dually withdrawn as the arm approached the 
fide. By thefe means the reduction was 
completed and confirmed. ' As the tendency 
to diflocation was fo great, the arm was kept 
for a few days in contact with the fide by a 
piece of girth web put round the arm and 
the body of the patient, who was difmiifed 
cured. 

REMAR K. 

I have ufed with advantage the method 
juft mentioned of preventing diflocation, when 
the tendency to it has been very great. 

Mr. Birkes of Rothwell, had the misfor- 
tune to diflocate the os humeri at the moulder, 
three times in the courfe of a few years. The 
Jaft of thefe accidents was produced merely 
by a horfe lifting up his head while he was 
putting on the bridle. His arm being hereby 
elevated fuddenly, the head of the os humeri 
was thrown out of its focket. I therefore 

advifed 



306 Ox Dislocations. 

achdfed hhn to wear a bandage round his ami 
and body, which fhould not fuffer the arm 
to recede fo far from his fide as to admit of 
a luxation. lie wore this for feveral years, 
and thereby prevented a repetition of the 
accident. 

€ A S E VII. 

October 22d, 1 793, Mr. D. aged fixty years, 
and a ftrong mufcular man, was brought to 
my lioufe in the evening from A. about 
fifteen miles from Leeds, on account of a lux.? 
ation of the right os humeri, which had hap- 
pened the preceding evening by a fall from 
his horfe. Attempts had been made in vain 
by an eminent furgeon to reduce the bone. 
The' head of the os humeri was funk under 
the thick pari of the peel oral mitfcie. After 
trying to effect, the reduction while my pa^ 
tient fat in a chair ; and finding, that in 
this wav I could not bring the. head of the 
bone fo far into the axilla as to feel it dis- 
tinctly, I placed him upon the carpet on the 
floor, with his right fide towards a table, on 
which flood two affiitants. By means of 
towels fattened round, or rather above, the 
condyles of the os humeri, they raifed his 
breech from the flpor. The extenfion made 



Otf Dislocations, 301 

by this effort in a vertical direction, drew 
the head of the bone into the axilla. It 
feemed to advance as far as the acromion, 
and grave a map aprainft the acetabulums fo 9 1<~>** ' 
that I concluded the head of the bone had " 

flipped into the focVet. Upon letting the 
arm fell, I found, however, that the bone 
was not reduced. I then attempted the re- 
duction with the heel in the armpit, and after- 
wards in Dr. Kirkland's method, but without 
fuccefs. 

I now took eight ounces of blood from Mr. 
D. and fent him to his inn in a chair : direct- 
ing the application of a bread and milk poul- 
tice to the moulder. A folution of the bitter 
cathartic felt was alfo given. 

After Mr. D. had left my houfe it occurred 
to me, that as the vertical extenfion had 
brought the head of the bone into contact 
with the acetabulum, I mould probablv have . ^. 

fucceeded in the reduction, if the affiftantW 
had moved forwards while the arm was in 
a ftate of extenfion, and had thereby in- 
clined it a little towards the horizontal po- 
rtion. 

23d. In the morning I took Mr. D. to the 
Infirmary, where Mr. Lucas and Mr. Logan 
met me at my requeft. Before any attempts 

were 



302 On Dislocations. 

were made to reduce the bone, fix ounces of 
blood were drawn from the arm, while Mr, 
D. flood upright* with the view of producing 
fome fickneis by the operation ; but the eva* 
cuation did not feniibly affefthim* 

Mr. Lucas having faid upoii a former oc* 
calion that he had not failed in his attempts to 
reduce a luxated flioulder fince he had applied 
the towels in the manner already deferibed * 
an attempt was made while Mr* I), fat in a 
chair, Mr. Lucas holding back the inferior 
part of the fcapula* This trial failed of fuc* 
cefs. The arm was afterwards extended in a 
vertical direction by means of puliies. 

I then put in practice the method which 
liad the preceding evening given the greateft 
hopes of fuccefs, with the additional move* 
ments that had occurred to me after Mr* D. 
had left my houfa. Two towels were fattened 
round the arm, as before, juft above and upon 
the condj^les of the os humeri; the fore-arm 
being placed at right angles to the arm, and fup* 
ported in that pofition by an affiftant. Each 
towel was held by a perfon ftanding on the 
counter of the fhop, while Mr. D. fat upon a 
carpet fpreaci on the floor. I directed the af- 
fiftants to elevate Mr. D. gently from the floor, 

and, 



On Dislocations. 303 

and, while he remained elevated, to moveflowly 
forwards in the direction in which his face 
was placed* By this method the arm was 
first extended vertically, and then with an 
angle, gradually approaching towards a hori- 
zontal pofition. I flood behind my patient, 
placing two fingers of each hand in the axilla, 
ready to pufh upwards the head of the bone, 
when I mould feel it advanced fufficiently in 
the axilla. Before the arm was brought 
down to an angle of 45 degrees with the 
horizon I made the requifite preffure upwards, 
and the head of the bone pafied into its 
focket. 

Mr. D. ftaid at Leeds till the next dav, 
and feemed to have fuffered left from the 
various attempts to reduce his arm, than one 
might have expected. ' He foon regained the 
ufe of his arm. 

Farther experience alone can determine 

whether this method of reduction is fuperior 

to thofe which I have mentioned before. 

It has this advantage, that it requires a very 

fmall number of afiiftants. One ftout man, 

or two at the moft, will suffice for elevating a 

lufty perfon from the floor in the manner 

directed. 

Whether, 



$04 On Dislocation's. 

Whether, in the former difficult cafes which 
I have related, the frequent extension of the 
mufcles had brought them into a ftate of de- 
bility and non-refiftance, and had thereby 
made our laft efforts fuccefsfui; or whether 
our last efforts were accidentally better adapt- 
ed to elude the difficulties which oppofed the 
reduction, Ifhall leave to the judgment of the 
reader. Perhaps both thefe caufes might 
contribute to our fuccefs. 

It will be obferved, that in feveral* of the 
cafes above recited, the counter extenfion 
w T as applied fo as to prefs back the inferior 
angle of the fcapula, and deprefs the acro- 
mion. This is contrary to the directions 
\&L given by Mr. Brom^ld in his Chirurgical 
\ Obfervations, who ufed to caufe the acro- 
mion to be pumed backwards, fo that the 
glenoid cavity might be feparated as far 
as poffible from the head of the os brachii 
during the extenfion. Thefe different me- 
thods of practice merit an attentive compa- 
rifon, that it may be decided on which fide 
the f^perioriry lies. 

. 
It is not completely fettled amongft Surgeons 

whether the fore-arm, during the extenfion, 

ought to be in a right line with the arm, or 

at 



On Dislocations, 305 

at right angles to it. Mr. Pott* and Mr. 
Thompfon-j* ftrongly recommend the latter; 
while Mr. White j is clearly of opinion that 
the former is preferable. Experience has not 
determined my mind on this point. My 
common method is to bend the fore-arm to a 
ri^ht angle with the arm ; but in fome of the 
moft difficult cafes which I have feen, fuccefs 
attended the attempts when the fore-arm was 
in a right line with the arm. 

If, in a diflocation of the moulder, the ten* 
don of the long head of the biceps mufcle is 
not torn from its groove in the os humeri, I 
fhould conjecture a priori, that the ft retch- 
ing of this tendon, by the extenfion of the 
fore-arm, would contribute to bring the head 
of the bone into conta6l with the glenoid 
cavity, as the tendon paffes from the head of 
the bone to the neck of the fcapula over that 
cavity. But if the tendon is torn intirely 
from its groove, it may be fo fituated as to 
form an impediment to the reduction, and in 
that cafe the relaxed ftate of the biceps muf- 
cle would be preferable. Mr. Thompfon 
found the tendon fo much removed from its 

* Pott's Works, vol. i. p. 468. 8vo. edit, 
t Med. Obf. and Inquiries; vol. ii, p. 344. 
t White's Cafes, p. Kg. 

X place. 



306 On Dislocations. 

place, and fo much ftretched by a prseter* 
natural curvature, that the fore arm could not 
be brought to a right line with the arm. 
When this is the cafe, it is undoubtedly pro- 
per to keep the biceps mufcle relaxed during 
the extemion. 

If the fore-arm can be eafily brought to a 
right line with the arm during the ftate of dis- 
location, and the furgeon willies to make the 
extenfion with the fore-arm in that direction; 
he may ftill conveniently apply the extending 
power to the diflocated bone, and prevent any 
injury to the joints of the elbow or wrift, by 
fixing the fore-arm in an extended pofition, by 
means of a flannel roller paffed round the 1 
elbow, and then applying the towels juft above 
the condyles of the os humeri. 

Opportunities of diffecting the moulder 
during a ftate of diflocation are fo rare, that 
we ftill remain ignorant of the precife nature, 
of the injury, done to the feveral parts con- 
cerned,, in ordinary cafes. Mr. Thompfon 
found the capfular ligament intirely torn off 
from the neck of the os humeri, the bone 
broken, and a fhell of it torn off by the 
tendons of the fupra & infra fpinatus mufcles. 
It appears alfo, that the long tendon of the 
biceps mufcle w r as torn from its groove, 

though 



Oisr Dislocations. 307 

though he does not exprefsly fay fo. But we can 
fcarcely imagine that fo much injury is done 
to the bone in every diflocation. Dr. Hunter 
was of opinion, from confidering the ftrufture 
of the joint, and from experiments made upon 
dead bodies, that the capfular ligament was 
lacerated in every diflocation of the fhoulder; 
but he did not carry his opinion fo far as to 
fuppofe that the ligament was always torn 
away from the neck of the os humeri, as in 
Mr. Thompfon's cafe, and as *Dr. Kirkland 
afterwards obferved in fome experiments made 
upon brutes. It is remarkable* that no in- 
fiance of diflocation of the os humeri fhould 
nave been found among the great number of 
bodies examined by that excellent anatomift 
Morgagni. He mentions one inftance of a 
luxation of the os femoris, but gives no other 
defcription of the ftate of the joint than that 
he found the round ligament relaxed.* 

I once faw a compound diflocation of the 
os humeri, the head of the bone being puihed 
through the integuments in the axilla, and in 

* Quod ad femur attinebat, re vera luxattim inven- 
tum eft, laxato videlicet eo ligamento quo femoris caput 
intra innominati offis acetabulum alligatur. 

Epift. LVI. Art. ?. 

X 2 tba* 



SOS On Dislocations. 

that cafe the long tendon of the biceps was 
torn from its groove in the neck of the bone ; 
the tendons of the fupra & infra fpinatus 
mufcles were alfo feparated- from the bone, 
and had torn off a large ihell of bone, as in 
the cafe related by Mr. Thompfon. 

Since the preceding obfervations were 
written, three cafes of drflocated os humeri 
have occurred at the General Infirmary, in 
which a method of reduction was ufed with 
fuccefs, which may probably prove beneficial, 
when the head of the bone is found lying 
behind the pectoral mufcle. 



C A S E VIII. 

Henry Baldwin, aged fixty-two years, was 
admitted a patient of the General Infirmary, 
January 23d, 1801, for u diflocation of the 
ihoulder. The head of the os humeri lay 
behind the pectoral mufcle at a confiderable 
diftance from the glenoid cavity of the 
fcapula. Very powerful extenfion, in a variety 
of directions, was ufed without - fuccefs. We 
could not, either by vertical or horizontal 
extenfion with pullies, bring the head of the 
bone into the axilla. After repeated fruitlefs 

trials, 



On Dislocations. 309 

trials, I directed that eight ounces of blood 
fhould be taken from the found arm; that the 
patient mould be put into the warm bath; 
that a purgative mould be given, and a mild 
poultice applied to the moulder till the next 

day. 

Thefe means removed the forenefs occa- 
fioned by the extenfion, and the next day 
the patient found himfelf as eafy as he had 
been before the extenfion waa ufed. 

As the head of the bone lay at a confider- 
able diftance from the focket, I was appre- 
henfive that the extenfion of the pecloral 
mufcle might have caufed a ftriclure upon the 
neck of the bone, and thereby prevented the 
head from returning into the axilla. I deter- 
mined therefore to try what a gentle motion 
of the bone in various directions, accompanied 
with a flight extenfion, would effc6fc. 

While I was ufing this method, without 
the aid of any affiftant, 1113^ colleague, Mr, 
Chorley, who was with me, put his hand upon 
the head of the bone, which he could feel 
through the pecloral mufcle, and thruft it 
towards the cavity of the joint. Our motions 
happening to correfpond, the head of the 
bone paiTed eafily into the axilla, and was 
then reduced without difficulty, two affiftants 

% 3 making 



310 On Dislocations. 

making the extenfion while I preffed upwards 
the head of the bone. 



CASE IX. 

John Brooksbank, aged fixty, and of a 
thin habit, was admitted March 9th 1801, 
under the fame circumflances. Mr. Logan, 
whofe patient he was, after fome ineffectual 
attempts to reduce the bone by ftrong extent 
lion, made ufe of the method which had fuc- 
ceeded in the preceding case. He moved the 
bone in various directions, while I preffed the 
head of it towards the glenoid cavity, into 
which after a few trials, it entered, and the 
patient was difmiffed cured. 

The fame method of reduction was ufed 
with fuccefs in the cafe of a middle-aged man, 
who was brought to the Infirmary in December 
laft, with a diilocation of the os humeri, the 
head of which lodged behind the pe6loral 
mufcle. 'Preflure upon the head of the bone, 
affifted by gentle extenfion, brought it into 
the axilla, and the reduction was then eafily 
.effected. 

It will readily be conceived, that violent 
extenfion of the mufcles may often clpfe up 
the fpace through which the head pf & diflo^ 

cated 



On Dislocations. 311 

cated bone mould return, when it has been 
driven to a great diftance from its acetabulum, 
and when this is the cafe, preffure made upon 
the head of the bone, with moderate extenfion, 
muft be a more fuitable method of praclice 
than the moft violent extenfion. 

I had ufed this method with fuccefs in a 
diflocation of the os femoris, nineteen years 
before the laft recited cafes occurred, as will 
be feen in the next cafe. 

Of the Diflocation of the Os Femoris, 

A diflocation of the os femoris at the hip- 
joint may happen two ways, either forwards 
and downwards, or backwards and upwards. 
My meaning is, that I have {ken it happen in 
thefe two ways ; for I leave to others the tafk 
ofdefcribing difeafes which they have not 
feen. Inftances of both thefe kinds of diflo- 
cation are rare. I have feen but three inftances 
of each in a courfe of forty-three years' prac- 
tice, though during thirty-four years of that 
period, I have attended an Infirmary in which 
cafes of accident are numerous. I will de- 
fcribe the fymptoms of both thefe fpecies of 
diflocation, and the method of reduction ufed in 

x 4 each 



312 On Dislocations. 

each cafe,. as clearly as I can; ajra I hope the 
young pra6titioner, whofe anatomical know* 
ledge is not defective, may obtain fome ufe- 
ful information from thefe defcriptions. 

One cafe, where the bone was diflocated 
backwards, was of fo long {landing, that it 
was judged to be incurable. The other two 
cafes were recent, and were treated with 
fuccefs in the fame manner ; fo that the recital 
of one cafe will afford all the information that* 
I can give on the fubje6t, 

CASE .X. 

In July 1782, a middle aged, and pretty 
ftrong, man, was brought into the General In* 
firmary, who, by the fall of a waggon against 
him, had fuffered the diflacation of the right 
os femoris backwards and upwards. 

The inferior extremity on the affefiled fide 
had an awkward appearance, It was con-, 
fiderably Ihorter than the correfponding limb. 
The toes were turned inwards. The thigh 
would not admit of a rotatory motion on its 
own axis, The limb could not be extended 
without pain to the patient. When he was 
laid in a prone pofition, the head of the os 
femoris might be felt through the gluteus 
«Wr maximus, 



Ox Dislocations. 314 

maximus, and nearly about the centre of that 
muscle. 

According to the belt judgment which I 
can frame from the anatomy of the parts, I 
fhould conceive, that the head of the bone lay 
at the edge of the facro-fciatic notch, near the 
inferior and pofterior edge of the gluteus 
medius. In this poiition, as the anatomical 
reader will readily conceive, the head of the 
bone lay toward the fpine, and the great 
trochanter towards the iide of the patient. 
There was no apparent contufion on the hip. 

To effect a redu6lion in this cafe it was 
evident, that the extenfion of the limb muft 
be made in a right line with the trunk of the 
body, and that, during the extenfion, the head 
of the bone muft be dire6ted outwards as well 
as downwards. It appeared alfo, that a ro- 
tatory motion of the os femoris on its own 
axis towards the fpine (the patient lying 
prone) would elevate the great trochanter, 
would bring it nearer to its natural pofition, 
and direct the head of the bone towards the 
acetabulum. Thefe circumftances being; well 
weighed in confutation, it was determined 
to proceed in the following manner : 

A folded blanket was wrapped round one 
of the bed-pofts, fo that the patient, lying in 

a prone 



314 On Dislocations. 

a prone pofition, and aftride of the bed-poft, 
might have the afifecled limb on the outfide of 
the bed. The bed was . rendered immov- 
able, by placing it againft a fmall iron pillar, 
which had been fixed for the purpofe of fup- 
porting the curtain rods. The leg was bent 
to a right angle with the thigh, and was fup~ 
ported in that pofition by Mr. Lucas, who, 
when the extenfion {hould be brought to a 
proper degree, was to give the thigh its ro- 
tatory motion, by pufhing the leg inwards, 
that is, towards the other inferior extremity. 
Mr. Jones fat before the patient's knee, and 
was to affift in giving the rotatory motion, by 
pumingthe knee outwards at the fame moment. 
I fat by the fide of the patient, to prefs the head 
of the bone downwards and outwards during the 
extenfion. Two long towels were wrapped 
round the thigh juft above the condyles, one 
towel paffmg on the infide of the knee, the 
other on the outfide. Three perfons made the 
extenfion; but when we attempted to give the 
thigh its rotatory motion, we found it con- 
fined by the towel which paffed on the infide 
of the knee and leg. We therefore placed 
both the towels on the outfide; and in this 
pofition the extending force concurred in 
giving the rotatory motion. The firft effort 



On Dislocations. 315 

that was made, after the towels were thus 
placed, had the defired effect, and the head of 
the bone moved downwards and outwards 
into the acetabulum. 

The man recovered very well. 



Thirty years had nearly elapfed, after the 
opening of the General Infirmary at Leeds, 
before any patient was brought to it with a dii- 
location of the thigh forwards and downwards. 
Nor had I, during a period of thirty-eight 
years, feen that accident in nay private prac- 
tice. During tha year 1797, three patients 
were brought into the Infirmary, who had 
.fuffered this accident. Though I had never 
feen this difeafe, yet I had carefully confi- 
dered it, and had determined to a6t, when 
called upon, according to the method laid 
down by Dr. Kirkland, the only author who 
had given me any fatisfactory ideas upon the 
fubjeft. I communicated thefe ideas to my 
colleagues, when this cafe firit occurred ; and 
meeting with their approbation, a method 
fimilar to that recommended by Dr. Kirk- 
land was purfued with fuccefs in all the 
patients. 

In this fpecies of diflocation, a3 the head 
of the bone is fituated lower than the aceta- 
bulum, 



316 On Dislocations. 

bulum, it is evident, that an extenfion made 
in a right line with the trunk of the body, 
muft remove the head of the bone farther 
from its proper place, and thereby prevent, 
inftead of affifting, reduction. The extenfion 
ought to be made with the thigh at a right 
angle, or inclined fomewhat lefs than a right 
angle, to the trunk of the body. When the 
extenfion has removed the head of the bone 
from the external obturator mufcle, which 
covers the great foramen of the os inriomi- 
natum, the upper part of the 03 femoris 
muft then be puftied or drawn outwards ; 
which motion will be greatly affifted by 
moving the lower part of the os femoris, 
at the fame moment, in a contrary direction, 
and, by a rotatory motion of the bone upon 
its own axis, turning the head of the bone 
towards the acetabulum. 

Before I relate the manner in which thefe 
three motions were effected, and combined, 
it will be proper to defcribe the fymptoms 
which indicated the exiftence of this diiloca- 
tion. The appearance of the affected . parts 
in all the thrqe patients was fo exactly finiilaf * 
that the defcription of any one of them will 
be fufficient. The head of the bone feemed 
removed to a fomewhat greater diftance from, 

the 



On Dislocations. 317 

the acetabulum in one patient, whofe cafe 
I mall now defcribe. 

CASE XI. 



Auguft 6th, 1 797, Simeon Slack, aged twen- 
ty-one years, was brought into the Infirmary,, 
on account of a diflocation of the right o* 
femoris, occafioned by a fall from his horfe. 
He was immediately put to bed, and placed 
in the pofition moft eafy to him. I found 
him lying upon his back, with his right thigh 
ftretched outwards, and refting upon a pillow, 
with his knee bent. Any attempt to bring 
the thigh nearer to a right line with the 
trunk of the body, gave him great pain, nor 
could it be brought nearer to a right line, 
without making a confiderable extenlion. 

The right thigh appeared much thicker 
than the left, at its fuperior and interior part. 
The mufcles were here upon the ftretch. 
The hollow which may ufually be felt between 
the flexor and extenfor mufcles, at the upper 
part of the thigh, was in this cafe filled up. 
The head of the bone could not be diftinfitly 
felt through the mufcles, yet from the appear- 
ance, and the touch, it was fufficiently evi- 
dent, that the head of the bone lay upon the 
great foramen of the os innominatum. It 

feemed 



318 Oisr iJisLocATiofts. 

feemed probable, that it had receded fo fa,r 
from the acetabulum as to be in contact with 
the defcending part of the os pubis. 

There was a confiderable hollow at the* 
upper and outer part of the thigh, where the 
great trochanter is ufually felt projecting. 

The right thigh appeared to be three erf 
four inches longer than the left. 

The foot of the affected limb was not 
turned outwards with refpect to the knee, but 
maintained its ufual relative poiition. 

The following method of cure was put in 
practice with fuccefs : 

The lower bed-poft,, on the right fide of 
the bed on which the patient lay* was placed 
in contact with a fmall immovable iron pil- 
lar (about an inch fquare in thickness), fuch 
as in our wards are ufed for fupporting the 
curtain rods of the beds. A folded blanket 
being wrapped round the bed-poft and pillar, 
the patient was placed aftride of them, with his 
left thigh clofe to the poft, and his right thigh 
on the outfide of the bed. A large piece of 
flannel was put between the blanket and the 
fcrotum, that the latter might not be hurt 
during the extenfion. 

The patient fat upright, with his abdomen 
in contact with the folded blanket which 

covered 



On Dislocations, 319 

covered the bed-poft. He fupported himfelf 
by putting his arms round the poft, and 
an affiftant fat behind him to prevent him 
from receding backwards. He was also 
fupported on each fide. 

Two long towels were put round the lower 
part of the thigh, in the manner before de- 
fcribed, after the part was well defended 
from excoriation by the application of a flan- 
nel roller. The knot, which the towels form, 
was made upon the anterior part of the thigh, 
that the motion intended to be given to the 
leg might not be impeded by the towels. 

The thigh being placed in a horizontal 
pofition, or rather a little elevated, with the 
kg hanging down at right angles to the thigh, 
I sat down upon a chair, dire&ly fronting the 
patient, and directed a gentle extenfion to be 
made by the affiftants Handing at my left 
fide. This was done with the view of drawing 
the head of the bone a little nearer to the 
middle of the thigh, and the extenfion had 
this effect. I then placed the two affiftants, 
who held the towels, at rny right fide, by 
which means the extenfion would be made in 
a direction a little inclined to the found limb. 
Mr. Logan flood on the right fide of the 
patient, with his hands placed on the upper 

and 



320 Osr Dislocations. 

and inner fide of the thigh, for the purpofe of 
drawing the head of the bone towards the 
acetabulum, when the extenfion fliould have 
removed it fufficieritly from the place in which 
it now lay* 

I defired the affiftants to make the exten- 
fion flowly and gradually ; and to give a fig- 
nal when it arrived at its greateft degree. 
At that moment Mr. Logan drew the upper 
part of the bone outwards, while I pufhed the 
knee inwards, and alfo gave the os femoris a 
confiderable rotatory motion, by pufhing the 
right leg towards the left. By thefe combin- 
ed motions the head of the os femoris was 
directed upwards and outwards, or, in other 
words, direcMy towards the acetabulum, into 
which it entered at our firft attempt made in 
this manner. 

The fcrotum, as the patient afllired me, 
was not hurt in the leaft by the extenfion. 

The other two patients, who were brought 
to the Infirmary in March preceding, had 
been treated on the fame principle, but every 
ftep in the operation was not fo diftinclly mark- 
ed. The firft was a boy, whofe thigh was re- 
duced while he fat upright, and aftride of the 
bed-poft. The fecond was a man twenty- 
ieven years of age, who was not brought to the 

Infirmary 



On Dislocations. 321 

Infirmary till the fixth day after the accident. 
A bone fetter had been fent for the day after 
the accident, who ufed great force by the 
afiiftance of eight or nine men, as the patient 
informed us. But as he made the extenfion 
in a right line with the trunk of the body, he 
failed of fuccefs. The patient was rendered 
fo fore by the extenfion, that he could not 
bear to be removed till the fifth day after- 
wards. 

I placed this patient in a fupine pofture, 
upon a bed laid on the floor. The extenfion 
was made by afingle perfon, who flood upon a 
chair, and held the thigh in a vertical pofition, 
or rather fomewhat inclined towards the pa- 
tient's abdomen. The motions given to the 
os femoris were nearly fimilar to thofe which 
I have defcribed, jand effected the reduction. 
The patient was able to walk about the ward, 
without crutches, before the expiration of a 
week. 

In all the three patients the affecled limb, 
immediately after the reduction, was longer 
than the found limb; but gradually regained 
its proper length. 

Y Di/locatiort 



322 'On Dislocations. 

Of the Di/location of the lower Jaw. 

The? practical obfervations" which I have to 
make on the treatment of this difeafe are few; 
but they may be of fome ufe to the young 
practitioner. 

One of the condyles of the lower jaw is 
often dhlocated while the other remains m its 
proper place, and it is not always eafy to 
know when this is the cafe. One would ex- 
pect, from a confideration of the ftructure of 
the parts, and from the defeription given in 
fyftems of furgery, that the chin iliould be 
evidently turned towards the oppofite fide; 
but I have repeatedly feen the difeafe, when 
I could difcern no alteration in the pofition of 
the chin. The fynip torn which I have found 
to be the beft guide in this cafe is, a fmall 
hollow which may be felt behind the condyle 
that is diilocated, which does not fubfift on 
the found fide. If the furgeon proceeds in 
the treatment of this partial diflocation, as if 
it had taken place in both condyles, he will 
throw an impediment in the way of the reduc- 
tion, and perhaps will be foiled in his at- 
tempts. 

The rnetliod of reduction recommended by 

fome 



On Dislocations. 323 

fome of our beft writers on furgery is, firft to 
pull the jaw forwards till it moves fome what 
from its fituation, and then to prefs it forcibly 
downwards, and moderately backwards. The 
firft part of this procefs does not appear to me 
neceifary from theory, and in pra6tice I have 
found it ufelefs, to fay the leaft. I have fuc- 
ceeded the beft by limply preffing the lower * 
jaw downwards, and backwards, with my 
thumbs placed as near the angles of the jaw as 
poffible. 

If both fides of the lower jaw are preffed 
upon, while one fide only is diflocated ; the 
reduction of the diflocated condyle is rather 
prevented. It is the beft method, therefore, 
to examine carefully whether both the con- 
dyles are diflocated, before any attempt is 
made, and to apply the force to that fide of 
the jaw only which has fuffered • diflocatiom 
I am inclined to think, that the application of; 
preffure to one fide of the jaw at once will 
not be injurious, even when both condyles 
are diflocated, having repeatedly fucceeded 
with eafe in a complete dislocation, by re- 
ducing the condyles fmgly, after I had made 
an unfuceefsful effort to reduce them both at 
the fame time. 

I have known two perfons in whom this 
y 2 diflocatioii 



324 On Dislocations. 

diflocation frequently happened. Not only- 
yawning, but even opening the mouth in- 
cautioufly in eating would caufe it. 

Of the Diflocation of the Thumb. 

A peculiar difficulty attends the reduftion, 
when the head of the metacarpal bone, which 
is joined to the firft phalanx of the thumb, is 
luxated completely, and depreffed towards the 
palm of the hand. A diflocation in the op- 
polite direftion is eafily reduced. 

A tranfverfe feclion of the anterior extremity 
of the metacarpal bone exhibits the form of a 
wedge, the narrower!: part being towards the 
palm of the hand. There are two tubercles on 
each fide of the anterior extremity of the meta- 
carpal bone, whence the lateral ligaments go off 
in part to the firft phalanx of the thumb. Upon 
meafuring the diftance of thefe tubercles from 
each other, I have found thofe two tubercles, 
which are neareft to the palm of the hand, to be 
only 3-8th»of an inch from each other, when 
the tubercles on the pofterior part of the fame 
bone were at the diftance of 5-8 ths of an 
inch. Suppofing therefore the head of the 
metacarpal bone to be preffed forcibly be- 
6 tween 



On Dislocations. 325 

tween the lateral ligaments, towards the palm 
of the hand, the extremity of the metacarpal 
bone paffes like a wedge between the lateral 
ligaments, and having paffed through between 
them, it cannot return, as the pofterior broad 
part of the bone prefents itfelf to the more 
contrafted aperture between the ligaments. 
From an anatomical consideration of the ftruc- 
ture of this joint, it feems impoffible that the 
metacarpal bone Should pafs in this direflion 
to a complete dislocation, without tearing off 
fome part of the lateral ligaments; yet fo 
much of the ligaments may remain, as to pre- 
vent the return of the bone to its natural 
Situation. 

Whether thefe obfervations account for the 
difficulty of redu6tion in this fpecies of dislo- 
cation, or not; I know from experience, that 
the redu6Hon is in fome cafes extremely 
difficult, if not imprafticable 

When I was a pupil at St. George's Hofpi- 
tal in the year 175 8, a patient, who had fuf- 
fered a dislocation of the thumb., was difmifSed 
incurable, the furgeons, who were men of the 
greateSt eminence, not being able to efieft the 
reduction. Mr. Bromfeild then informed the 
pupils, that he had known a furgeon increafe 
the force of extension to fuch a degree, in at- 

y 3 tempting 



h 



526 Oisr Dislocations. 

tempting reduction in this diilocation, that 
he tore off the thumb at the fecond joint. 

In the year 1767 Mr. Billam, at that time 
a furgeon in Leeds of confiderable experience, 
came to my houfe with a young man, who by 
falling againft a ftone had diflocated the me- 
tacarpal bone of the thumb, in the manner 
above defcribed. Mr; B. had attempted the 
reduction in vain, and we had jointly no 
better fuccefs. We tried not only by ext'en- 
iion, accompanied with preffure upon the dif- 
located extremity of the bone, but alfo by 
giving the bone a kind of rotatory motion on 
its own axis ; but all in vain. This cafe led 
me to examine the joint attentively, both in 
the fkeleton, and in a preparation of the joints 
kept in fpirits; and caufed the obfervations 
which I have noted above. 

I was lately called to an accident of this 
kind, and being foiled in my firft attempts to 
reduce the bone, I defired the patient to keep 
her hand in a mild poultice for feveral days, 
intending to repeat my attempts. But the 
patient would not fuffer me to make another 
trial; fatisfying herfelf with putting a cover 
of leather upon her thumb. Whether me had 
made application to any other furgeon after 
my firft failure, I do not know. 

€HH-A-*V 



[ 327 ] 
CHAP. VI. 

On internal Derangement of the 
Knee Joint. 



The joint of the knee is fo firmly fupported 
on all fides by tendinous and ligamentous 
fubftances ; that the bones of the thigh and 
leg are very rarely feparated from each other, 
fo as to form a dijlocation, in the common 
fenfe of the term. Great violence muft take 
place, and a confiderable laceration muft hap- 
pen, before the tibia can be completely fepa- 
rated from the os femoris. Yet this joint is 
not unfrequently aflfe6ted with an internal de- 
rangement of its component parts ; and that 
fometimes in confequence of trifling accidents. 
The difeafe is, indeed, now and then removed, 
as fuddenly as it is produced, by the natural 
motions of the joint, without furgical affift- 
ance : but it may remain for week\s or months, 
and will then become a ferious misfortune, as 
it caufes a confiderable degree of lamenefs. 
I am not acquainted with any author who has 
defcribed either the difeafe or the rerriedy; 
I shall, therefore, give fuch a defcription as 
my own experience has furmmed me with, 
arid fuch as will fuffice to diftinguiih a com- 

y 4 plaint, 



328 Internal Derangement 
plaint, which, when recent, admits of an eafy 
method of cure. 

This diforder may happen either with, or 
without, contufion. In the latter cafe it is 
readily diftinguimed. In the former, the 
fymptoms are equivocal, till the. effects of the 
contulion are removed. When no contufion 
has happened, or the effects of it are removed, 
the joint, with refpect to its fhape, appears to 
be uninjured. If there is any difference from 
its ufual appearance, it is, that the ligament 
of the patella appears rather more relaxed 
than in the found limb. The leg is readily 
bent or extended by the hands of the furgeon, 
and without pain to the patient : at moft, the 
degree of uneafinefs caufed by this flexion and 
extenfion is trifling. But the patient himfelf 
cannot freely bend, nor perfectly extend the 
limb in walking; but is compelled to walk 
with an invariable and final] degree of flexion. 
Though the patient is obliged to keep the leg 
thus ftiff in walking; yet in fitting down the 
affected joint will move like the other. 

The complaint which I have described may 
be brought on, I apprehend, by any fuch al- 
teration in the flate of the joint, as will pre- 
vent the condyles of the os femoris from 
moving truly in the hollow formed by the 

femi- 



op the Knee Joint. 329 

femilunar cartilages and articular depreffions 
of the tibia. An unequal tenfion of the la- 
teral, or crofs ligaments of the joint, or fome 
flight derangement of the femilunar cartilages, 
may probably be fufficient to bring on the 
complaint. When the diforder is the effect 
of contufion, it is moft likely that the lateral 
ligament on one iide of the joint may be ren- 
dered fomewhat more rigid than ufual, and 
hereby prevent that equable motion of the 
condyles of the os femoris, which is neceffary 
for walking with firmnefs. 

The method of cure, which I am about to 
propofe, mult not be ufed while there is any 
inflammatory affection, or fwelling of the 
joint; but only when thefe effects of contufion 
are removed. The following cafes will farther 
illuftrate the nature of this complaint ; and 
point out the method which I have hitherto 
found fuccefsful in removing it, 

CASE L 

In 1782, I wasdefired to vifit the late Wil- 
liam Sotheron, Efq. of Darrington ; and found 
him affefted with an inability of moving the 
joint of one knee. This complaint came 
upon him fuddenly, the morning of the day 

preceding 



330 Internal Drraugement 

preceding my vifit, as be was turning himfelf 
in bed. He felt fome pain at the infertion of 
the tendon of the biceps femoris into the 
head of the fibula ; and that tendon feemed 
to be rather upon the ftretch; in other re- 
fpefts the appearance of the joint was per- 
fectly natural. As Mr. S. was then, in an 
emaciated ftate from other complaints, I had 
an opportunity of examining the joint to the 
greateft advantage. There was no fwelling in 
any part of it. I could bend and extend the 
affecled limb as readily as that which re- 
mained uninjured. There was no protrufion 
of the femilunar cartilages. My patient felt 
no pain when I preffed my fingers upon the 
joint in any direction. He informed me, 
that he had twice before had a fimilar lame- 
nefs, which at both times had left him in- 
ftanteoufly. He was chiefly uneafy at the 
continuance of this attack. 

He had occafion to walk out of the room 
foon after my arrival ; and I then obferved, 
that he could not place his foot flat upon the 
floor, nor bend the joint as ufual when he 
raifed the affected limb in walking. 

Soon after his return into the room, while 
he flood talking with me, he cried out on a 
f add en, " I am quite well/' and immediately 

was 



of the Knee Joint. 331 

was able to walk about without the leafl 
degree of lamenefs- 

CASE II. 

In 1784, the honourable Mifs Harriet 
Ingram (now Mrs. Afton), as fhe was play- 
ing with a child, and making a conliderable 
exertion, in ftretching herfelf forwards, and 
{looping to take hold of the child, while me 
refted upon one leg, brought on an imme- 
diate lamenefs in the knee joint of that leg 
on which fhe flood. The diforder was con- 
fidered as a fimple fprain; and a plafter was 
applied round the joint. As the lamenefs 
did not diminifh in the courfe of five or fix 
days, I was defired to vifit her. 

Upon comparing the knees, I could per- 
ceive no difference, except that, when the 
limbs were placed in a ftate of complete ex- 
tenfion, the ligament of the patella of the 
injured joint feemed to be rather more relaxed 
than in that joint which had received no 
injury. When I moved the affefted knee 
by a gentle flexion and extenfion, my patient 
complained of no pain; yet fhe could not 
perfectly extend the leg in walking, nor 
bend it in railing the foot from the floor; 

but 



332 INTERNAL DeRANGEMESTT 

but moved as if the joint had been ftifiy 
limping very much, and walking with pain. 

I thought it probable, that the fudden 
exertion might in fome degree have altered 
the fituation of the crofs ligaments, or other- 
wife have difplaced the condyles of the os 
femoris with refpecT: to the femilunar car- 
tilages; fo that the condyles might meet 
with fome renftance when the flexor or ex~ 
tenfor mufcles were put into a&ion, and 
thereby the free motion of the joint might 
be hindered, when the incumbent weight of 
the body preffed the thigh bone clofely 
againft the tibia; though this derangement 
was not fo great as to prevent the joint, 
"when relaxed, from being moved with eafe. 

To remedy this derangement, I placed 
my patient upon an elevated feat, which had 
nothing underneath it that could prevent 
the leg from being puftied backward towards 
the pofterior part of the thigh. I then ex^ 
tended the joint by the affiftance of one hand 
placed juft above the knee, while with the 
other hand I grafped the leg, During the 
continuance of the extenfion I fuddenly 
moved the leg backwards, that it might 
make as acute an angle with the thigh as 
pofiible. This operation I repeated once, 

and 



of the Knee Joint. 333 

and then deiired the young lady to try how 
fhe could walk. Whatever may be thought 
of my theory, my practice proved fuccefsful; 
for lhe was immediately able to walk without 
lamenefs, and on the third day after this 
reduction me danced at a private ball with- 
out inconvenience, or receiving any injury 
from the exercife. 

CASE III. 

In October 1786, the young lady, who 
is the fubjecl; of the laft cafe, had the mis- 
fortune to produce the fame injury in her 
knee, in rifing haftily out of bed. After 
the lamenefs had continued about a week, 
without any amendment, I was confulted. 
The method of cure above defcribed was 
made ufe of, with the fame immediate fuc- 
cefs. 

CASE IV. 

Matter Thompfon of Hull, a young gen- 
tleman at Mr. Hodgfon's academy in Leeds, 
fuffered a contufion and fprain of the knee joint, 
by climbing up behind a poft-chaife in motion, 
the wheel of which caught hold of his leg, 

and 



334 Internal Derangement' 

and gave it a fevere twift. I faw him a few 
hours after the accident. The joint was 
fwelled, and in- a very painful ftate. I di- 
rected him to be put to bed; and ufed fuch 
remedies as I judged moil likely to prevent 
inflammation. The fwelling and pain foon 
went off; fo that he was able, at the expira- 
tion of a week, to move about. A piafter 
was then put round the joint, and he was 
permitted to walk out. 

From this time there was no improvement 
in the motion of the joint. He could run, 
but it was in a very awkward and imperfect 
manner, for he could not fet his foot flat 
upon the ground. He was obliged in walk- 
ing to reft uoon his toes whenever he raifed 
the found limb from the ground, and to keep 
the knee a little bent, being incapable of 
extending the limb in a progreflive motion. 
A perfon, obferving the manner in which 
he performed this exerciie, would have 
thought his knee to be ftiff; yet there ap- 
peared to be no rigidity in the joint, when 
it was moved by the hands of another perfon, 
while he himfelf fat in a chair. 

When he had remained in this ftate nearly 
a fortnight, without any amendment, I was 
perfuaded that the condyles of the os femoris 

were 



of the Knee Joint. 335 

were prevented from moving in a true direc- 
tion upon the tibia and lemilunar cartilages, 
either by fome irregular contraction of the 
tendinous or ligamentous fubftances furround- 
ing the joint, or by fpme other caufe of in- 
ternal derangement, which time might rather 
increafe than remove. I determined, there- 
fore, to attempt his relief by the method 
above mentioned. I extended, and then 
bent the limb to a coniiderable degree, re- 
peating the operation two or three times. 
He was enabled immediately to walk in a 
natural manner, and in a few days regained 
the perfect ufe of his limb. 

CASE V. 

In Oaober 1790, the Rev. Thomas Dikes 
of Hull, who then lived at Berwick in Elmet 
near Leeds, fuffered a contufion of the knee, 
by the fall of his horfe, as he was riding. 
The cuticle was rubbed off in fome places. 
A violent pain was brought on, which conti- 
nued in the knee for about an hour and half 
after the,accident; and the joint during this 
time became fwelled and difcoloured. In 
the courfe of a week the fwelling fubfided. 
The ceratum faponis was then put round 
the knee, and he was permitted to walk 

a little. 



335 Internal Derangement, &c. 

a little. At the expiration of a month after 
the accident, his power of walking was not 
at all increafed, yet the injured knee appeared 
like the other. I could bend and extend 
the limb without difficulty, and without 
giving him pain; but when he walked he 
could give the joint no motion by the natural 
efforts of the mufcles. He walked, to ufe 
his own expreffion, " as if he had no joint 
in the knee." 

Thefe fymptoms led me to hope that I 
might be of fervice to him by the extenfion 
and flexion which I have defcribed. But as 
the joint had remained fo long without its 
proper ufe, 1 could fcarcely flatter myfelf 
with the expectation of immediate fuccefs. 
I extended and bent the limb with rather 
more force than I had ufed in the preceding 
cafes; yet upon the flrft trial he could not 
ufe the joint fo well as I wifhed. I repeated 
the operation after the interval of a few^ 
minutes, and he immediately regained the 
power of walking as well as ufual, except 
that he felt a little weaknefsJfor a few days. 

I have ieen feveral cafes of this difeafe 
befides thofe above defcribed ; but the fymp- 
toms and treatment being fimilar, I fhall not 
trouble my reader with a recital of them. 



m 



[ 337 ] ; 

CHAP. VIL 

On loose Cartilaginous Substances 
in the Joints. 



THE exiftence of loofe cartilaginous fub* 
ftances in the joint of the knee, has been 
noticed by feveral modern authors. The 
method of extra&ing thefe fubftances, and 
that of treating the patient after the oper- 
ation, have been defcribed by Mr. Bromfeild 
in the appendix to his firft volume of Chirur- 
gical Obfervations ; and by Mr* Ford in the 
fifth volume of Medical Obfervations and 
Inquiries. This operation is confidered by 
thefe authors as the only method of cure. 
But, although it has often been attended 
with fuccefs, yet, as the late Medical Society 
have obferved, it has fometimes " been fol- 
lowed with violent inflammation, fever, and 
death itfelf." It would therefore be of fer- 
vice to mankind, could a method be invented 
of curing this diforder with fafety, or render* 
ing it of no inconvenience to the patient. 

Z Such 



338 On loose Cartilaginous 

Such a method I have found, in a few 
inftances, in the ufe of a well-adapted laced 
knee-cap. And as in one of thefe inftances 
the difeafe was more than ufually trouble- 
Jbme, I think I do not exceed the bounds of 
probability in hoping, that it will generally 
prove fuccefsful; at any rate, it deferves a 
trial before the dangerous operation of open- 
ing the joint is attempted : efpecially as there 
is reafon to believe, that, in fome cafes, loofe 
cartilaginous fubftances, or fubftances refem- 
bling them, are capable of becoming diffolved 
in the joint, without the affiftance of any 
remedies. 

€ A S £ I. 

In October 1781, Mr. Snowden, an ap- 
prentice to a linen-draper in Leeds, confulted 
me on account of a loofe hard fubftanee, 
which he had lately felt in the joint of the 
knee. It feemed to be about the Jize of a 
hazel-nut. It paffed very readily from one 
part of the joint to another upon a gentle 
preffure, and during the ordinary motions 
of the limb. He became fenfible of the 
exiftence of this loofe fubftanee in the joint 
ibon after his recovery from the effects of a 

contufion 



Substances in the Joints. 339 

contufion of the knee, which he had fuffered 
from a fall; before which accident he had 
not the leaft complaint in the parL 

While this fubftance remained in the in- 
terior parts of the joint, he could walk with- 
out inconvenience; but whenever it got be- 
tween the condyles of the os femoris and the 
tibia> fo that he could feel it through the 
capfular ligament, it gave him pain, and 
produced lamenefs. 

Thefe circumftances induced me to think* 
that the application of a knee-cap, laced 
clofely, might retain the fubftance within 
the interior parts of the joint; or, at leaft, 
prevent it from remaining fo long between 
the condyles of the os femoris and the tibia, 
as to create much uneafmefs. The utility 
of this bandage exceeded my expectation : 
for he not only found no inconvenience from 
the moveable fubftance after he began to 
wear the knee-piece ; but at the expiration 
of twelve months he affured me, that he was 
no longer fenfible of the exiftence of the 
difeafe, even when he walked without his 
bandage. 



Z 2 CASE- 



340 On loose Cartilaginous 



CASE II. 

Oaober 26th, 1781, Mr. Brigham, houfe- 
fteward to the late General Cary, confulted 
me on account of two loofe fubftances in the 
joint of the knee, which rendered him unable 
to go about his ufual employment, without 
considerable difficulty and pain. He in- 
formed me, that, about two years before, 
he had the misfortune to flip down a declivity 
in the front of Leven-grove houfe, the feat 
of General Cary ; and thereby received fo 
violent a fprain in his knee, that he was for 
a time unable to walk. When the immediate 
effe6ls of the fprain were removed, he firft 
perceived the fubftances in the joint. A va- 
riety of applications were made ufe of to 
relieve his lamenefs ; and the application of 
a cauftic was recommended for the removal 
of the loofe fubftances ; but to this propofal 
he would not confent. He had no degree 
of lamenefs or weaknefs in the knee, previous 
to the accident I have mentioned; but was 
flout and active. 

Upon examining his knee, I found two 
loofe and hard fubftances within the capfular 
ligament. They moved rapidly? upon pref- 

fure, 



Substances in the Joints. 341 

fure, from one part of the joint to another. 
I could fometimes feel them both at the 
fame time; but never found them in contafil 
with each other. There was alfo a fmaller 
cartilaginous fubftance (fo I judged it to be) 
attached to the exterior part of the tendon 
of the vaftus externus femoris. This was 
alfo moveable to a certain diftance, and 
feemed to be fituated on the outfide of the 
capfular ligament, Thefe fubftances incom- 
moded him fo much upon motion, that he 
was frequently compelled to flop in walking; 
and the pain which they caufed was often 
fo acute, as to make him cry out. 

I found it more difficult to reftrain the 
motion of the loofe fubftances in this cafe, 
than in that of Mr. Snowden ; and therefore 
procured a quilted knee-piece, which was 
made under my infpe&ion, I took fin exa6l 
meafure of the knee ; and made the quilting 
to proje6t in tw r o places, where the knee-piece 
was to prefs upon the hollow part of each 
fide of the patella: for there the fubftances 
ufually made their appearance. I a/Ivifed 
Mr. Brigham to wear alfo compreffes of plafter 
fpread upon leather, on each fide of the pa- 
tella, if the quilting Ihould not fufficiently 
reftrain the motion of the loofe cartilages. 

z 3 General 



342 On toosE Cartilaginous 

General Cary informed me, in April 1 784, 
that Mr, Brigham, though not perfectly well 5 
could walk about with eafe, and even run, 
and leap, without injuring himfelf, or ufually 
exciting pain, Wifhing to know theiffue of 
this cafe, I wrote to Mr. Brigham, requeft- 
ing him to inform me of the prefent ftate of 
his knee. In his anfwer, dated Auguft lft, 
1 79 1 , he gives me the following account : 

" After I had worn your bandage a few 
tt days, laced very tight, I found my knee 
" near perfectly well ; and when 1 keep the 
" bandage tight it continues fo ftill, and has 
" done ever- fince 1 was with you at Leeds : 
" but I can find the lumps not at all reduced, 
* c though they are no hindrance to me in any 
" common exercife. But before I made ufe of 
" the bandage, I was not able to walk with- 
" out the afliftance of either crutch orftick." 

In January 1792, Mr. Brigham called 
upon me at Leeds. He had ceafed wearing 
the quilted bandage for feveral years, and 
now wore only a common laced knee-cap. 
The fubflances produced no impediment in 
walking, and were now feldom perceived. 
After a trial of ten years he had found this 
mode of treatment to anfwer every purpofe he 
defired, 

CASE 



Substances iff the Joints. 343 

CASE lit. 

Auguft 1788, Mr. Lee, of LeaconfielcU 
park, near Beverley, confulted me, and gave 
me the following account of his complaint : 

About three months before his application 
to me, he received a violent ftroke, from a 
horfe, upon his knee ; which caufed a eonfi- 
derable fwelling of the joint. Three or four 
weeks after this accident, w r hen the fwelling 
was difperfed, he perceived a fmall moveable 
fubftance in the joint, which gave him great 
uneafmefs in walking. He confulted a furgeon 
of eminence in the neighbourhood, who ad- 
vifed the extraction of the fubftance, as the 
only method of cure. 

Being apprehenfive that the operation 
would be attended with fome degree of dan* 
ger, he was unwilling to fubmit to it without 
the concurrent opinion of fome other furgeon, 

I recommended the ufe of a laced knee- 
piece ; from which he found fuch relief, that 
he could immediately walk with eafe and 
firmnefs. 

September 20th, 1 791 , Mr. Lee called upon 
me in his road to Buxton, and informed me, 
that he had continued to w 7 ear the knee-piece 

2 4 till 



344- Ois\ loose Cartilaginous 

till within the laft month ; when the rheuma* 
tifm, affecting his knee as well as fome other 
joints, had rendered the wearing of the band-* 
age painful. He had not felt the loofe fiib- 
ftance for about two months before he left 
off the ufe of his bandage ; nor had he felt 
it fince the bandage had been removed. 

CASE IV, 

Being at York upon bufinefs,, I was re- 
quefted by the late Rev. Mr, Cappe to 
examine the elbow of Mr. W, Lee, of Leeds, 
who was then under his tuition. This young 
gentleman had hurt the joint confiderably 
by a fall in the ftreet, betwixt five and fix 
weeks before I faw him. I did not fee the 
furgeon who had attended him; but was 
informed, that the extremity of the Olecranon 
was fuppofed to have been broken off, from 
the exiftenpe of fome loofe fubftances, which 
were difcoyered in the, joint upon the fubfiding 
of the fuelling caufed by the contufion. 

Upon examination I could readily feel two 
loofe, hard, and roundifh fubftances in the 
joint. The fwelling being entirely difperfed, 
I could alfo diftin6tly feel the extremity of 
$he Olecranon ; and was perfuao'ed, that the 

fubftances 



Substances in the Joints. 345 

fubftances which I found in the joint were 
not pieces of bone broken off from that pro- 
cefs. Mr. Lee could move the arm with 
freedom, and was not much incommoded by 
thefe fubftances. 

The fubftances gradually diminifhed ; and 
at laft became entirely diflblved, as I fhould 
fuppofe, for they could not be felt in any 
pofition of the joint, 

I cannot afcertain the period of the diflb- 
lution, as I very rarely examined the joint ; 
and as feveral years intervened between my 
firft and laft examination of it. 



REMARKS. 

When the preceding cafes occured, I had 
not feen Reimarus's Thefts De Fungo Articu- 
lorum ; nor did I know, that bandages had 
been tried, and had been found ufeful in 
fome inftances for this complaint. The late 
Mr. Middleton, ferjeant-furgeon to the army, 
informed Reimarus that he had cured a patient 
by the application of plafter and bandage 
to the knee ; fo that upon removing the 
bandage, after it had been applied fome 
months, the difeafe did not return. Mr. 

Middleton 



346 On loose Cartilaginous 

Middleton knew another cafe in which the 
lame treatment had proved fuccefsfuL But 
it is added, what 1 ought not conceal, that 
the fame method had been tried in St, 
George's hofpital without fuccefs, in one 
inikniice ; m which the pain was increaled 
while the fubftance was kept under the pa- 
tella, although the patient had before found 
relief from this treatment. The fubftance 
was therefore removed by incifion into the 
Joint *. 

Thefe loofe fubftances differ fomewhat in 
their ftructure. Some have been found upon 
examination to be fmall bones, covered witk 
e cruft of cartilage; while others have been 
found cartilaginous throughout. 

The origin of thefe fubftances remains yet 
obfcure. Mr. Ford thinks it moft probable* 
that in his patient, " the cartilage was prima- 
rily attached by fmall ligaments to the 
joint, but at length increafing in bulk, it 
was feparated from its attachment by the 
injury received in the fall/'-f* In one 
inftance, mentioned by Reimarus, fome dif- 
eafe feems to have exifted in the joint before 
the patient fufFered that contufion of the 

* Sec Reimarus de Fun go Articulorum, ^ 27, 54, &c. 
f Medical Qbf, and Inquiries, vol. 5. p. 329. 

6 knee ? 






.Substances in the Joints, 347 

knee, which was followed by the perception 
of a loofe fubftance. 

" Mget liie in Nofoc. Georg. licet in eo- 
M dem gen a dolorem aliquem jam a tribus 
" annis fenferat, accedente et a multo motu 
" tumore ; hsec tamen gravia non fuifle, nee 
" corpufculum illud omnino fe percepifle aie- 
£ bat antequam genu laeferit." lb. 

In thofe inftances which have occurred in 
my practice, the patients had neither the 
leaft degree of lamenefs, nor of weaknefs in 
the knee, prior to the injuries which they 
fuffered in the joint. And this feems to have 
been the cafe in almoft all the inftances which 
have been 'published, where any notice is 
taken of the patient having fuffered an in- 
jury in the joint. 

As diffe6lions of the knee have fometimes 
difcovered the exiftence of cartilaginous fub- 
ftances, attached to the interior parts of the 
joint by fmall pedicles ; and as thefe fub- 
ftances, when loofe, may be fo confined 
within the joint as to create neither pain nor 
lamenefs; the idea of their being detached, 
rather than caufed to exift, by the accidents 
which have preceded the perception of them f 
feems very rational. On the other hand, as 
the caufes of the generation of thefe morbid 

appen- 



348 On loose Cartilaginous, &c. 
appendages of the joints is totally unknown 
to us ; and as they have fo often been firft 
perceived after the joint had fuffered fome 
confiderable contufion ; it is not improbable, 
that in fome cafes the morbid ftate of the 
joint, after fuch contufion or other injury, 
may give rife to their produ&ion. This feems 
to have happened in the 4th of the preceding 
caiesu $> 

If any cafe mould occur, in which the 
patient can obtain no relief from a well-adapt? 
ed bandage; but is under the neceffity of 
fubmitting to the extra6lion of the loofe 
fubftance, thefurgeon ought to attend to the 
advice given by the late Medical Society, 
in the poftfcript tq Mr. Fords paper on this 
fubject. 

" Besides fuch chirurgical management 
u as may be thought beft for keeping the 
" lips of the wound in perfect contact, the 
* c limb mould be kept immovable, and every 
" thing mould be avoided than can either 
" irritate the part, or heat the body/* 



[ 349 ] 

CHAP. VIII. 
On Wounds of the Joints. 



THE operation propofed for extracting 
loofe cartilaginous fubftanees from the joint 
of the knee, leads me to offer a few remarks 
on wounds of the joints, a fubjeQ; of confider- 
able importance in the practice of furgery. 
The obfervations of the Medical Society, 
above quoted, very judicioufly point out the 
danger of fuch wounds, and the proper 
treatment for preventing the bad confequences 
which often arife from them. 

The utmoft care mould be taken in thefe 
cafes to prevent inflammation. Upon this 
circumftance chiefly depends a fuccefsful ter- 
mination. I have feen many large wounds 
of the gfeat joints healed without the fuper- 
vention of any dangerous fymptoms, where 
due care has been taken to prevent inflam- 
mation ; while injuries, apparently trifling, 
will often be followed by a train of diftreffing 
and dangerous confequences, where fuch care 
has been neglected. It is generally eaiier to 

prevent 



350 On* Wouwds of the Joints. 
prevent inflammation in the joints, after a 
wound, than to arreft its progrefs when once 
begun. I fpeak now of inflammation affect- 
ing the capfular ligament. A flight degree 
of redness and tenderness in the integuments 
only is of little consequence; but when the 
capfular ligament becomes inflamed, the for- 
mation of abfceffes, attended with a high 
degree of fever, and ultimately a fliffnefs of 
the joint, are the common consequences, if 
the life of the patient is preserved. The reci- 
tal of a few cafes will illuftrate this fubjeft, 
and point out the great advantage of timely 
care to prevent inflammation when a joint is 
wounded. 

CASE I, 

In 1787, Mr. Hargrave, a joiner and 
master-builder in Leeds, happened to fall, as 
he was walking up fome fteps into his ware- 
houfe, and to ftrike the end of his thumb 
against one of the fteps. By this accident 
he suffered a compound diflocation of the 
laft joint of his thumb. He immediately 
replaced the bones, which returned to their 
proper fituation with eafe. Finding no great 
degree of pain after the reduction, and not 

aware 



On Wounds of the Joints. 351 
aware of any bad confeque nee from a wound 
of the joint, he did not immediately apply 
for any furgical afliftance. He wrapped a 
linen rag round the thumb, and continued 
to go about his buiinefs, hoping that the 
wound would foon be healed. The next day 
he covered his thumb with cerate, and re- 
mained free from any considerable degree of 
pain till the evening. Inflammation now 
began to take place, which foon occupied the 
whole of his hand, and extended along the 
fore-arm up to the elbow. In this ftate of 
the difeafe I was confulted; but it was to<* 
late to prevent a high degree of inflamma- 
tion, accompanied with much fyrrmtomatic 
fever, and the formation of feveral large ab- 
fcenes in the fore-arm, alonsr the courfe of 
the lymphatics. Notwithftanding the ufe 
of bleeding, purgative and other cooling me- 
dicines, the application of the mildeft poul- 
t-ices, with a ftri6l attention to reft, and a 
horizontal pofition of the limb, the fever ran 
fo high that he ^was fometimes a little deli- 
rious. As the abfeeffes were chiefly formed 
beneath the fafcia of the mufcles, I made 
inciiions through the fafcia wherever I could 
perceive a fluctuation of matter. Thefe oper- 
ations diminished the tenfion of the limb, 

abated 



$52 On Wounds of the Joints. 

abated the fever, and feemed to be the 
means of preferring the life of my patient* 
I was obliged to make feveii incifions (fome of 
them large) at different times, in the fore- 
arm, and two on the back part of the hand* 
Upon his recovery, however, no injury re- 
mained, except a ftiffhefs of the laft joint of 
the thumb, whicri had fuffered the compound 
diflocation. 

CASE Hi 

/ 

In 176 7 , I was defired to vifit James 
Oakes, aged thirty years, who, in cutting 
fome wood* which he held againft his knee, 
with a {harp femi-circular knife, fuch as the 
coopers ufe, had divided the ligament of 
the patella, and a portion of the capfular 
ligament on each fide of the patella. The 
accident had happened fome weeks before I 
faw him. I found the knee fwelled, fome- 
what inflamed about the internal condyle of 
the thigh, and very painfuL The leg, though 
now kept conftantly in a horizontal pofition, 
was oedematous. 

Mr. B. who was attending him, had intro* 
duced a feton at the external part of the 
wound, and had drawn it through an opening 

made 



On Wounds of the Joints. 353 

made on the outfide of the thigh, a little 
above the external condyle, for the purpofe 
of affording a free difcharge to the matter of 
an abfcefs formed there. His pulfe was very 
frequent, and he was obliged, on account of 
the pain, to take fixty or feventy drops of 
laudanum every night, which did not, how- 
ever, procure much reft. 

There was no apparent inflammation in the 
ham, when I firft faw him, but in the courfe 
of a few days an abfcefs began to form itself 
there, which was opened as foon as the part 
became fufficietitly prominent. The purulent 
matter which was difcharged, was dark co- 
loured, and very fetid. After this opening, 
the fwelling of the leg abated $ and the mat- 
ter, having a free exit* became better con- 
ditioned. The matter infinuated itfelf fome- 
what beneath the integuments of the leg and 
thigh ; but by an enlargement of the wound, 
and the application of rollers, the extenfion 
of the matter was prevented. 

The painful ftate of the joint, and the 
fymptomatic fever abated. Before the ex- 
piration of January, his pulfe was come down 
to ninety, and he flept moderately in the night 
time, fometinies without an opiate. The 
feton was removed, and he was now permit- 
ted to fit up every day. 

A a February 



35b On Wounds of the Joints. 

February 1 1th, his pulfe was at fixty-two. 
The wounds after this time healed favourably, 
but a ftifmefs of the joint remained. 

CASE III. 

In 1784, a ftout young man was brought 
into the Infirmary at Leeds, with a tranf- 
verfe wound penetrating the knee joint juft 
above the patella. Mr. Lucas had the care 
of the accident-patients this week ; but as he 
was out of town, I was requefted to attend 
to this cafe. 

The patient had been working in the woods s 
and, a woodman's bill had fallen from a bough 
above him, and ftriking the loweft part of the 
thigh, had made a tranfverfe wound about 
two inches in length, dividing the tendon of 
the reftus femoris clofe to the patella. A 
wound was made through the capfular liga- 
ment, fo large that I could eafily introduce 
my finger into the joint. 

After examining the interior parts of the 
joint with my finger, that no extraneous 
body might be left there, I united the lips 
of the wound by three flitches of the inter- 
rupted future, taking care to lay hold of no- 
thing with the needle but the integuments. 
I could not remove all the blood from the 

infide 



Qn Wounds of the Joints. 355 

infide of the joint, for that continued to flow 
as long as my finger remained in the wound. 
Neither could I favour the difcharge of that 
blood which remained in the joints by any 
method of placing the limb which would 
anfwer my principal intention. But I hoped 
that, if inflammation could be avoided, the 
extravafated blood would be abforbed with- 
out danger. 

That I might keep the knee quite fteady, 
and the injured parts in a ftate of relaxation, 
I placed the man in a fiipine pofture, with 
his leg upon a pillow in a heavy fracture-box, 
and covered the wound with ceratum faponis* 
fpread upon a pledget of tow. This method 
kept the anterior parts of the knee, with the 
rectus femoris, in a ftate of the greateft relax- 
ation; and the external air was excluded 
without making any preffure upon the in- 
jured parts. I gave directions that all poffi- 
ble care fliould be taken to prevent the motion 
of the joint upon any occafion; 

The patient complained of fmarting in the 
wound for about half an hour after the dref- 
fing, but had afterwards no return of pain. 

Mr. Lucas continued the fame treatment, 
and cut out the ligatures upon the tenth day 
after the accident. The patient recovered 

a a 2 fo 



556 On Wounds of the Joints. 
fo well* that in the fpace of four weeks he 
became able to move about in the ward upon 
crutchesi 

He regained the perfect ufe" of his limb. 

C A S E IV. 

October 4th, 1798, Sarah Swordie, aged 
eighteen years, was brought into the Infir- 
mary, on account of a wound in the elbow- 
joint, which me had juft received from the 
wadding of a piftol, fired very near her, 
during the rejoicing for Admiral Nelfons 
vi6tory over the French fleet, in the Bay of 
Aboukir. The wound was made near the 
olecranon, through the flat tendon of the 
extenfor cubiti. The parts were contufed 
and lacerated. The capfular ligament was 
divided fo as to admit readily the introduce 
tion of a finger within the joint. A confider- 
able number of grains of gunpowder were 
lodged in the integuments. I examined 
carefully the cavity of the joint, but could 
not find any extraneous fubftance lodged 
there. 

Though it was not probable, from the 
contufed ftate of the parts, that an union 
by the adhefive procefs could be obtained; 

1 y et > 



On Wounds of the Joints. ' 357 

yet, in order to diminifh as much as poffible 
the fize of the wound, and exclude the ex- 
ternal air, I drew the integuments into con- 
tact by fome ftitches of the interrupted future. 
The young woman being put to bed, I 
placed the arm upon a pillow, in an extended 
pofition, that, the wounded parts might be 
kept in a ftate of relaxation. The arm was 
covered with a poultice made of bread and 
water. An opiate was given immediately, 
and a gentle laxative the next morning. 
The young woman was not fufFered to get out 
of bed on any occafion, nor was her arm re- 
moved from the pillow except when gently 
raifed for the purpofe of applying the poul- 
tice. 

The fymptoms of inflammation were tri- 
fling, and foon went off. The integuments 
had been fo much contufed, that the liga^ 
tures did but retain the wounded parts in 
contact for a few days. The edges of the 
wound then floughed off, but the fize of the 
wound was diminifhed by the lips having 
been retained in contact for fome days. The 
arm became quite eafy in the courfe of 3 few 
days. 

On the 1 4th day I laid afide the poultices, 

A a 3 md 



358 On Wounds of the Joints. 

and drew the lips of the wound towards each 
other with flicking plafter. 

^he patient regained the perfe6t ufe of the 
elbow] and J)ecember 5th was difcharged 
cured, 

CASE V, 

William Hide, aged twenty-one years, was 
brought into the Infirmary, May 9th, 1799? 
qn account of a wpund which he had juft 
received in the ancle-joint by & hatchet. 
The ftroke had been given in a perpendicular 
direftion^ and the inftrument h^d not only 
divided the capfular ligament, but had alfq 
cut off a portion of the articular extremity 
of the tibia, about an inch in length and half 
an inch in breadth; and a fmaller portipq. 
from the edge of the aftr^galus. I diffe6le4 
out the former ; but the latter lay fo deep in 
the wound, and was fo ftrongly attached tq 
fhe foft parts, that I judged it to be the 
moft prudent meafure to leave it in the 
wound, as I fhoujd not have been able to 
take up any blood-veffel that might have 
been wounded in the diffe6lion. Befides ? 
the attachment of this fmall piece of bone 
to the foft parts was fo ilrong, that I was 

under 



On Wounds of the Joints. 359 

under no apprehenfion of its being caft off, 
or becoming injurious, to the joint. The 
integuments were united by future, and the 
limb was placed in the mod eafy pofition in 
bed, after being covered with a mild poultice. 

The future treatment of this patient was 
committed to Mr. Logan, in whofe abfence 
I had taken care of him, who placed the 
limb in a fra6lure-box upon the third day 
after the accident. The inflammation was 
trifling. The poultice was continued about 
a fortnight. At the end of the third week 
the patient was allowed to fit up, the wound 
being nearly healed ; and at the expiration of 
the fourth week the wound was completely 
cicatrized. He was now directed to move 
the joint, and to walk a little; but by too 
great exertions he brought on an inflamma- 
tion about the joint. Reft, with the repeated 
application of leeches, and the aq. litharg. 
acet. comp. removed the inflammation. 

June 24th, he was made an out-patient, 
and was foon after that difcharged cured, 

CASE VI. 

Gervafe Hodgfon, a little boy, about five 
years of age, playing in the fields at the 

a a 4 time 



360 On Wounds of the Joints. 

time of harveft, received a wound from a 
fey the, which divided the capfular ligament 
of the ancle-joint, and took -off a fmall piece 
of bone on the inner fide of the extremity of 
the tibia. He was brought to the Infirmary, 
and fell under my care. I united the divi- 
ded integuments by future, taking care to 
avoid any pun£ture of the capfular ligament. 
The limb was wrapped in a poultice, and 
the patient confined to his bed. The inte- 
guments became inflamed, and the futures 
burft open. An abfeefs was formed on the 
oppofite fide of the ancle, the opening of 
which gave him great relief. It was about 
two months before the wounds were healed? 
but he regained the perfect ufe of his ancle, 

CASE VII. 

John Senior, aged nine years, was admit* 
ted into the General Infirmary May 2d 
1801, on account of acontufed and lacerated 
wound in the right arm. He was following 
a large iron roller, drawn by a horfe, in the 
fields, and was holding a rope in his hand, 
which happened to become entangled with 
the roller while in motion, in fuch a manner 
that his arm was fuddenly drawn beneath the 

roller. 



Oisr Wounds of tue Joints. 36j 

roller. A large wound was made in the 
elbow-joint and the arm, both of which had 
fuffered great contufion. The capfular liga- 
ment of the joint was laid open; and the 
articular extremity of the os humeri was 
broken obliquely upwards, fo that the greater 
part of the internal condyle of the bone was 
feparated from the external, in the hollow 
which lies between thefe two projections. 

As the external condyle of the os humeri, 
and the bones of the fore-arm remained un- 
injured, as the great blood veffels were en- 
tire, and the mufcles had not fuffered any 
confiderable laceration, I determined to at- 
tempt the prefervation of the limb. I firft 
differed out all the broken pieces of bone, 
and after placing the integuments in their 
natural fituation, I united them by the in- 
terrupted future. I wrapped the arm in a 
poultice of bread and water, and placed it 
in the moil eafy pofition upon a pillow in 
bed. The limb was kept in this pofition, 
except when elevated for the purpofe of ap- 
plying the dreffings. 

The contufion had been fo great, that the 
integuments were caft off on the inner fide of 
the arm, from one to two inches in breadth, 
from the elbow to the axilla, but no inflam- 
mation 



36'2 Ok Wounds of the Joints. 

mation enfued. The boy was quite, eafj% 
except during the times of dreffing the wound. 
-A finus was formed under- the integuments 
at the axilla, which I was obliged to open. 
The ufe of the poultice was continued till the 
tumefa&ion of the limb had completely fub~ 
fided, and the wound was filled with gra- 
nulations. 

At the expiration of five weeks he was 
able to walk about the houfe. He was made 
an out-patient July 10th, and in Auguft 
was difcharged cured. 

After the boy was made an out-patient, 
the granulations became fpongy , and fome- 
what foul, and the wound fee'med indifpofed 
for cicatrization i In this ftate he received 
great benefit from the following application^ 
which is often Angularly ufeful in fcrofulous 
fores, when the granulations are fpongy. 

R . Aq. purse % xv. 

Spt. Rorifmarin. % j. 

• — Lavend. c. 3 j. 

Zinci vitriolat. 3 fs. fiat Solutio. 

The fores were kept constantly covered 
with folded linen wet with this folution, withr 
out any other dreffing. It was applied afre^i 
three or four times a day. 

CASE 



On Wounds of the Joints. 363 

CASE VIII. 

I was defired by Mr. Wormald, furgeon, 
who now refides at Harrowgate, to vifit the 
fon of John Baraclough, of Adwalton, and to 
take with me every thing neceffary for the 
amputation of his arm. 

A cart, in which the child was riding to the 
hay field, had been overturned, and its upper 
edge falling upon his right arm, had cut the 
elbow joint quite acrofs, on the anterior fide* 
and had broken the inferior part of the os 
humeri tranfverfly, about an inch and half 
above its articular extremity. Below this 
fra6lure the end of the bone was alfo broken 
in different directions. The extenfor muf- 
cles were not injured, and there remained 
fo large a portion of the flexors undivided, 
that I thought the boy might enjoy a con- 
fide rable ufe of his arm, if the wound in the 
joint could be healed. 

I differed out the whole extremity of the 
ps jjumeri from the part where it had fuf- 
fered the tranfverfe fra6lure ? and after bring- 
ing the integuments into contact, I placed 
the limb gently bent . t at the elbow upon a 
pillow, and furrounded with a mild poultice. 

The 



364 Osr Wounds of the Joints, 

The fymptoms confequent upon this acci- 
dent and operation were extremely favour- 
able. No inflammation fupervened. The 
froy recovered, and was able to perform the 
motions of flexion and extenfion with his 
arm, though the joint which had fufFered fo 
great a lofs was not fo firm and ftrong as 
that of the other arm. 

Being defirous of knowing how far the 
fun6lions of the arm could be performed with 
the lofs of the inferior articular extremity of 
the os humeri, I lately requefted this patient, 
who is now fifteen years of age, to call upon 
me, that I might have an opportunity of 
examining the prefent ftate of his arm. 

May 18th, 1802, he favoured me with a 
call, and permitted me to make fuch an exa- 
mination as I thought proper. 

The cicatrix extended from the tendon of 
the biceps to the olecranon, and was fituated 
on the exterior fide of the joint. 

The tendon of the extenfor triceps was 
attached, as ufual, to the fuperior part of the 
ulna; but the olecranon might be moved in 
any direftion, having now no fupport from 
the condyles of the os humeri. I could 
eafily place my fingers on the hooked extre- 
mity 



On Woukds of the Joints. 365 

niity of the olecranon, which now lay on the 
inner fide of the os humeri. 

The inferior extremity of this bone extend- 
ed downwards below the higheft part of the. 
ulna, and was attached to the middle of the 
cicatrix. 

There was a round bag, about the fize of 
a large nutmeg, containing fome fluid fub- 
ftance, united with the extremity of the os 
humeri, and lying betwixt it and the olecra- 
non. It feemed probable to me, that this 
might be a part of the capfular ligament, 
which I had left upon diffecling out the ex- 
tremity of the os humeri, and which, having 
attached itfelf to the end of the bone, was 
now filled with fynovia. 

The head of the radius could not be felt. 
It feemed to be funk deep amongft the muf- 
cles of the fore-arm, and was covered by the 
extremity of the os humeri. 

The length of the mutilated bone was about 
an inch and half lefs than that in the found 
arm^ 

The right fore-arm was moderately muf- 
cular and plump, but not fo thick as the 
left. Above the elbow the right arm was 
much fmaller than the left. 

The 



366 Ok* Wounds of the Joints 

- The young man could perform the mo- 
tions of flexion and extenfion very readily 
with the right arm; but not thofe of pro- 
nation and fupination with the fore-arm 
&lone* He imitated this motion very well 
by giving a rotation to the whole arm. 

He could place his hand upon his head, 
by giving the arm a 1 winging motion; but 
he could not lift-a glafs of wine to his mouth. 
His father informed me, that he could lift 
heavy weights, and do many other things 
with his arm in a depending polition e 

I was informed that he could write pretty 
well with the right hand ; and I obferved that 
Jhe made ufe of his right hand fo as to give 
considerable affiftance to the left, in putting 
on his neckcloth, "which I had removed for 
the purpofe of meafuring the length of his 
arms. 



■[ 367 ] 

CHAP. IX. 

Compound Luxation of the Ancle. 

Joint. 



WHEN the fibula is broken near the joint 
of the ancle, the tibia almoft always suffers a 
partial diflocation. If the integuments are 
not lacerated by the tibia, it is eafily replaced, 
and with due care the fracture may be cured 
without injury to the joint. But when the 
force is very great, which produces this 
frafture, the extremity of the tibia fome- 
times burfts through the integuments, and 
thus forms a compound luxation of the joint. 
This is a very ferious accident, and the beft 
mode of treatment has not yet been afcer- 
tained by furgical writers. Probably there 
are few furs;eons who have feen a fufficient 
number of thefe cafes to enable them to form 
a decifive judgment on this fubject* 

The late Mr. Gooch, who was an able 
furgeon, fays, " If the furgeon mould judge 
f* it advifable to attempt faving a limb under 

•« fuch 



368 CoMPouftB Luxation 

" fuch threatening circumftances, I am in- 
" clined to think he will be more likely to 
" fucceed by sawing off the head of the bone, 
" efpecially if it has been long quite out, 
* c and expofed to the air.*" 

He then relates, a cafe of this kind, in 
"which Mr. Cooper of Bungay fawed off 
both the head of the tibia and fibula, by 
which means he preferved the limb, and 
made it fo ufeful, that the patient was able 
to walk and work for his bread; of which 
fuccefs Mr. Gooch was a witnefs. Encou- 
raged by this fuccefs, I purfued the fame 
method of cure in the following cafe. 

CASE 1. 

September 16th, 1766, Mr. W. Hebderi* 
about fifty-fix years of age, was attacked by a 
bull, which threw him down, and caufed & 
compound luxation of the tibia at the right 
ancle. The fibula was broken near the ex- 
tremity of the tibia. The head of that bone* 
which lies below the tibia* remained attached 
to the aftragalus. There was a confiderable 
laceration of the integuments and capfular 

* Gooch's Cafes in Surgery, p. 103, ed. 1st. 

ligament 



ot the Ancle Joint. 369 

ligament on the inner fide of the ancle; but 
on the outer fide they remained whole. The 
tendo achillis, as well as the flexor and ex- 
terifor tendons of the foot, appeared to be 
uninjured. About two inches of the ex- 
treme part of the tibia lay expofed, which 
I fawed off, together with the correfponding 
part of the fibula. The leg was afterwards 
placed upon its outfide, in a relaxed pofition., 
and was covered with a poultice, An opiate 
was given. 

2d day. He had refted well. Pulfe ninety- 
five ; full and hard. Nine ounces of blood 
were taken from his arm. 

3d day. Pulfe ninety-eight; not fo fulL 
Had refted tolerably without an opiate. A. 
folution of cathartic fait was given. 

4th day. Pulfe feventy. Wound looked 
well. 

6th day* Pulfe feventy-fix. Suppuration had 
taken place in a part of the legi a little above 
the wound* which had been bruifed by the 
bull. The matter had pafFed into the w r ound, 

9 th day. I made an opening on the outer 
fide of the tendo achillis, to difcharge the 
matter lodging in the wound, now become 
rather too ofienfive. Granulations (hoot up 
well from the fides of the wound. 

Bb nth 



370 Compound LuxaSon 

1 1th day. Pulfe eighty. The matter was 
difcharged in part through the depending 
orifice. Granulations had arifen from the 
Cartilaginous covering of the aftragalus. 

15th day. Pulfe feventy-fix. A large 
Hough of the capfular ligament lay in the 
wound. Quantity of pus diminifhed. The 
bruifed part above now difcharged very little 
matter. Bandage is now ufed without poul- 
tice, 

1 8th day. Pulfe fixty-eight. The wounded 
part began to feel ftiffer. 

2 2d day. A glairy fluid began to appear 
in the wound. The Hough was caft off about 
this time. The wound continued to lefFen 
very fail, being filled with granulations. His 
appetite^good. He had been allowed animal 
food as foon as the firft inflammatory fymp- 
toms ceafed. 

From this time he recovered well, and I 
left him to the care of the furgeon who had 
been firft called in. 

I was in hopes that this patient would 
have been able to walk ftoutly; but in this 
I was difappoiiited. He walked indeed with- 
put a crutch, But his gait was slow, his leg 
remaining weak, and his toes turning out- 
wards, which rather furprized me, as his leg 

was 



of the Ancle Joint. 371 

was very ftraight when I ceafed attending 
bim. 

A light fteel fup porter, as recommended 
by Mr. Gooch, ought to have been ufed in 
this cafe when the patient began to walk 
abroad. 

I have not recited this cafe with the view 
of recommending a fimilar practice in all 
cafes of this accident, for I have not always 
adopted it; nor am I of opinion, that the 
fame mode of treatment, whether by replac- 
ing the bones, fawing oft their extremities, 
or amputating the limb, ought to be uni- 
verfally praclifed. When the laceration of 
the capfular ligament and integuments is no 
greater than is fufhcient to permit the head 
of the tibia to pafs through them, and when 
at the fame time the joint or contiguous parts 
have fuffered no other injury, I mould re- 
commend the replacing of the bone, and an 
union of the integuments by future, with the 
fubfequent treatment above recommended in 
wounds of the joints. 

CASE II. 

In September 1793, I was defired to vifit 
a young man at Walton, near Wakefield, 

B B 2 who, 



372 Compound Luxation - 

who, by being thrown out of a wifkey the 
preceding evening, had fuffered a compound 
diflocation of the tibia at the ancle. The 
furgeon who was attending him had replaced 
the bone not long after the accident, and 
had put fplints upon the leg, with a pretty 
tight bandage. I found the limb fomewhat 
fwelled, with a tendency to inflammation. The 
orifice, through which the tibia had pafied, 
was confide rably clofed. Under thefe cir- 
cumftances I did not think it neceffary or 
proper to make, any future of the integu- 
ments; but after removing all compreffion, 
I placed the leg in a bent pofition on its 
outer fide, and applied a mild poultice. The 
patient recovered extremely well; but about 
three months after his cure an ulcer took 
place in the integuments which had been 
lacerated, and finding that this did not heal 
readily, he came to Leeds to put himfelf 
under my care. After the ulcer was healed, 
which happened in the courfe of three weeks, 
I procured a iteel fupporter, as the ancle was 
rather weak, and the tibia had a tendency to 
project inwards. This enabled him to walk 
with eafe. 

If the laceration of the joint be very great, 

and the contufion confiderable. I Ihould judge 

2 . it, 



of the Ancle Joint. 373 

it the mod fafe method to amputate the leg; 
but I am ftrongly inclined to think, that 
the lofs of the limb is rarely nece flaxy in a 
compound luxation of the tibia, "which is 
not attended with any other injury, except 
a frafture of the fibula, and this mult of 
courfe take place whenever fuch a luxation 
occurs, unlefs the aftragalus is alfo diflocated. 
.Mr. Gooch relates a cafe of this kind, but 
fpeaks of it as a lingular accident. I have 
ieen one, and but one inftance of it. The 
reduction of the bones was impracticable, 
and amputation was judged to be abfolutely 
neceiTarv. The cafe which I faw occurred 
in 1758, when I was a pupil of St. George's 
Hofpital in London. The patient was a cor- 
pulent woman, who in alighting from a horfe 
on which fhe had been riding fmgle, happened 
to catch hold of the fiirrup with the heel 
of one llioe. In confequence of this (lie 
came down to the ground upon the other 
foot, with fo much violence that the inferior 
extremities of the tibia and fibula, together 
with the aftragalus, were forced through the 
capfular ligament and integuments. Mr. 
Bromfeild, whofe patient fhe was, finding re* 
auction to be impracticable, immediately ampu- 
tated the leg, but the woman did not recover, 

b b 3 



C 374 ] 

CHAP. X. 
'n Retention of Urine. 



A Retention of urine in the bladder, when; 
the natural efforts are incapable of affording 
relief, is, in male fubjecls, a difeafe of great 
urgency and danger. This retention may 
arife from a variety of caufes, which operate 
as a mechanical impediment to the flow of 
urine; fuch as ftri£hires in the urethra^ cal- 
culous concretions fixed in any part of that 
canal, abfceffes in the penis or perinaeum, 
&c. each of which rnuft require a fpecific 
mode of treatment. It is not my deiign, 
however, to enlarge upon thefe caufes of 
Retention; but to conlider the difeafe in its 
moft iimple ftate, and to confine my obfer- 
vations chiefly to that mode of relief, which 
arifes from the ufe of the catheter. 

Perfons advanced in years are more fub- 
je6t to thi§ complaint than thofe who are 
young, or middle aged. It is often brought 
on by an incautious refiftance to the calls of 
nature; and, if not fpeedily relieved, gene- 



On Retention of Urine. 375 

rally excites fome degree of fever. It is 
fometimes attended with a confiderable de- 
gree of fever, and an inflammatory affection 
of the bladder, which terminates in a dis- 
charge of purulent matter, and a fatal hectic. 

The diftinttion, which has fometimes been 
made, between a fupprejjion and retention of 
urine is practical and judicious. The former 
moil properly points out a defect in the 
fecretion of the kidnies ; the latter, an inabi- 
lity of expelling the urine when fecreted. 

The difeafe of which I am fpeaking, under 
the term retention of urine, is, an inability 5 
whether total or partial, of expelling, by the 
natural efforts, the urine contained in the 
bladder. The character iftic fymptom of this 
difeafe, previous to the introduction of the 
catheter, is a diftenfion of the bladder (to be 
perceived by an examination of the hypo- 
gaftrium), after the patient has difcharged 
all the urine which he is capable of expelling. 

As this complaint may fubfift, when the 
flow of urine from the bladder is by no means 
totally fuppreffed* great caution is required 
to avoid miftakes on this fubject. 

Violent efforts to make water axe often 
excited at intervals, and during thefe {train- 
ings fmall quantities of urine are expelled. 

B b 4 Under 



376 On Retention of Urin$. ■ 

Under thefe circuniftances, thediforder may 
Ibe miftaken for the ftrangury. 

At other times, a morbid retention of 
urine fubfifts, when the patient can make 
water with a ftream, and difcharge a quan-. 
tity equal to that which is commonly dis- 
charged by a per fon in health. Under this 
circumftance, I have known the pain in the 
hypogaftrium, and diftenfion of the bladder,, 
continue, till the patient was relieved by the 
catheter. 

And laftly, it fometimes happens, that 
when the bladder has fuffered its utmoft 
diftenfion, the urine runs off by the urethra, 
as fad as it is brought into the bladder by 
the ureters. I have repeatedly known this 
circumftance caufe a ferious mifapprehenfion 
pf the true nature of the difeafe. 

In every cafe of retention of urine which 
I have feen, the difeafe might be afcertained 
by an examination of the hypogaftrium, 
taken in connection with the other fymptoms. 
The diftended bladder forms there a hard 
and circumfcribed tumour ? giving pain to the 
patient when preffed with the hand. Some 
obfcurity may arife upon the examination of 
a very corpulent perfon; but in all doubtful 
caies the catheter mould be introduced. 



On Retention of Urine. 377 

I have feen but a few cafes of the [fchuria 
renalis, or complete fuppreffion of the fecre- 
tion of urine bv the kidnies. The difeafe 
proved fatal in all my patients except one 3 
in whom it was brought on by the effect of 
lead, taken into the body by working in a 
pottery. It fublifted three days, during a 
violent attack of the colica piftonum, and was 
then removed, together with the original dif- 
eafe. I found no difficulty in diftinguifhing 
this diforder, in any of the cafes, from the 
ifchuria vejicaMs, though, for the fatisfaftion 
of fome of my patients, I introduced the 
catheter. 

Before I proceed to defcribe that method 
of introducing the catheter which I have 
found moft fuccefsful, I fhali premife a few 
anatomical obfervations on the parts con- 
cerned in this operation; and mall point out 
the principal difficulties which occur in it 5 
when the difeafe is in its moll fimple ftate. 

In all operations on the parts contained 
within the pelvis, it is necefiary to keep in 
mind the angle which the axis of the pelvis 
forms with that of the abdomen. When the 
body is upright, the offa pubis approach 
confiderably towards a horizontal petition. 
Now, as the bladder is connected with the 

pofterior 



378 Ojst Retention fo Urik t e. 

\w* pofterior furfaee of the oila pu|is, the de- 
preffed poiition of thefe bones gives a consi- 
derable curvature to the membranous part 
of the urethra, which pafles round their 
inferior angle. This part of the urethra is 
about an inch in length. Its coats are thin. 
They are unprotected by the corpus caverno- 
£um, and are immediately furrounded by a 
yielding cellular and adipofe membrane. The 
proftate gland, when divided horizontally , 
fame what refembles the figure of a heart 
ftamped upon a, pack of cards. Its point is 
turned towards the offa pubis. The urethra 
enters the gland at its point, and pafles 
through it, running upwards and a little 
backwards. The greater part of the proftate 
irland lies behind the urethra. The neck of 
the bladder defcends lower before than be- 
hind, and is much Strengthened in its ante- 
rior part with mufcular fibres. 

In our attempts to introduce the catheter, 
we Should have regard to the curvature of 
the urethra, its connexion with the conti- 
guous parts, and the manner in which it 
paffes through the proftate gland. If the 
curve defcribed by the point of the catheter, 
in an attempt to introduce that instrument, 
is lefs than the curve of the urethra, it is 

evident, 



On Retention of Urixe. 379 

evident, that the point of the catheter will 
be pufhed againft the pofterior part of the 
urethra, inftead of following the courlfe of 
that canal. The pofterior part of the urethra 
has nothing contiguous to it which can fup- 
port it; and no confiderable degree of force 
is neceflary to puih the point of the catheter 
through that part, between the bladder and 
the rectum. If this accident is avoided, 
ftill the point will be pufhed againft the in- 
ferior furface of the proftate gland, and can- 
not, in this direction, enter the bladder. 

The truth of this ftatement is farther ma- 
nifeft from the affiftance which one receives, 
in the introduction of the catheter (whenever 
it ftops at the proftate gland), by elevating 
the point of the inftrument with a finger in- 
troduced within the rectum. This gives a 
greater curvature to the courfe of the inftru- 
ment, and facilitates its entrance into the 
proftate gland. When I come to defcribe 
the ufe of the flexible catheter, I (hall men- 
tion another method of giving the point of 
the inftrument a direction confiderably curved, 
while it paffes through the membranous part 
of the urethra, and farther illuftrate the ad- 
vantage of this manoeuvre. There is no great 
danger of pufhing the point of the catheter 

through 



$■80 On Retention op Urine. 

through the anterior coats of the urethra, as 
they are fupported by the offa pubis, and as 
the urethra enters and paffes through the 
proftate gland in a direction nearly vertical. 

The difficulty of performing this operation, 
arifing from the caufes above mentioned, 
ftiews the impropriety of pufhing forwards 
the point of the catheter before its handle is 
fufficiently depreffed. If the catheter is punn- 
ed on while its handle is in a vertical pofition, 
it is evident that the point muft move in a 
horizontal 'direction. Any force ufed in this 
direction greatly endangers the wounding of 
the urethra. But if the catheter is pufhed 
forwards when the handle is in a horizontal 
pofitiqn, the point of the inftrument will then 
afcend in a vertical direction, which is the 
moft proper for its paffing through the mem- 
branous part of the urethra, and proftate 
gland, without injury. 

Another difficult v, which fometimes occurs 
in the introduction of the catheter, arifes. 
from the inflamed and dry ftate of the 
urethra. In this cafe the catheter does not 
move freely in the urethra, and the proper 
turns cannot be made with eafe and exactnefs. 

The previous introduction of a bougie, well 
covered with lard, 'greatly facilitates, in this 

cafe, 



Ox Retention of Tjrixe. 3$ I 

cafe, the pafiage of the catheter. But great 
caution mould be ufed if the bougie meets 
with reliftance, as even this inftrument is 
capable of penetrating the coats of the ure- 
thra, when its point does not take a proper 
direction. 

CASE I. 

I was called one morning to affift a young 
man, who had been in great pain all the pre- 
ceding night from a retention of urine, and 
who had been drinking freely of gin, to en- 
able him to make water. I immediately 
made ufe of an elaitic gum catheter, covered 
with frefh lard, which entered the urethra 
without difficulty. It had fcarcely paffed 
half the length of the penis, when the reiift- 
ance became fo great from the adhefion of 
the urethra to the inftrument, that I thought 
proper to withdraw it. That part of the 
catheter, which had been in the urethra, 
appeared dry as if it had been wiped w r ith a 
cloth. I then introduced a fmall bougie, 
w r ell anointed, which dilated and moiftened 
the urethra; and thereby enabled me to 
introduce the fame catheter with eafe. 
v 

Having premifed thefe general obferva- 
tions. I mall proceed to point out the method 

of 



382 On Retention* of Urine. 

of directing the catheter, which I have found 
moil effectual. 

I place my patient upon a bed, in a re- 
cumbent pofture, his breech advancing to, or 
projecting a little beyond, the edge of the 
bed* f . If the bed is fo high, that his feet do 
not reft upon the floor, I fupport the right 
leg by a ftool, or by the hands of an affif* 
tant. The patient's head and fhoulders are 
elevated by pillows ; but I leave the lower 
part of the abdomen in a pofition nearly, if 
not entirely, horizontal. I commonly intro- 
duce the catheter with its convex fide towards 
the abdomen; and, having gently pufhed 
down the point of the inftrument, along the 
fymphyiis pubis, till its paffage in that direc- 
tion is (topped by the curvature of the ure- 
thra, I turn the handle of the catheter to- 
wards the navel, preffing at the fame time its 
point againft the fymphyfis pubis. Without 
this prefiure, the point of the inftrument is 
apt to recede, and in that cafe it does not 

* I prefer a recumbent to an ere& pofture, becaufe it 
is eafier to the patient, and keeps him more fteady during 
the operation. Befides, as this pofture is often neceffary 
on account of the patient's weaknefs, and is, to fay the 
leaft, equally convenient; I give it the preference, that 
I may not fuffer any embarraifment from being compel- 
led to doit in a pofition to which I am not accuftomed. 

readily 



On Retention of Urine. 383 

readily enter the membranous part of the 
urethra In making the turn I fometimes 
keep the handle at the fame diftance from the 
patient's abdomen, and fometimes make it 
gradually recede; but in either method I 
avoid pulhing forwards the point of the ca- 
theter any farther than is neceffary to carry it 
juft beyond the angle of the fymphyfis pubis- 
When I feel that the point is beyond that 
part, I pull the catheter gently towards me, 
hooking, as it were, the point of the inftru- 
ment upon the pubis. I then deprefs the 
handle, making it defcribe a portion of a cir- 
cle, the centre of which is the angle of the 
pubis. Vvlien the handle of the catheter is 
brought into a horizontal pofition, w T ith the 
concave fide of the inftrument upwards, I 
puih forwards the point, keeping it as clofe as 
I can to the interior furface of the fymphyfis 
pubis; for when paffing in this direction, it 
will not hitch upon the proftate gland, nor 
injure the membranous part of the urethra'^. 

* In giving inftructions to my pupils refpe6ting this 
operation, J advife them to conduct the inftrument as if 
the urethra was glued to the fymphyfis pubis on both 
ikies (that is, b)th within and without the pelvis) ; ob- 
ferving that, il hough this is not anatomically true, the 
idea will lead them to a& in a manner moft conducive 
to a fueceisful and fafe introduction of the catheter. 

Thefe 



384 Ok Retention of Urine/ 

Thefe directions are equally applicable^ 
whether the furgeon, in making the turni 
moves the catheter flowly, without taking 
hold of the penis, as Mr. Ware advifes * ; or 
moves it fomewhat rapidly , holding the penis 
in the left hand, as other authors have ad- 
vifed. 

They are applicable alfo when the catheter 
is introduced with its concave fide towards 
the abdomen -j*, except that inftead of making 
the turn, the handle muft from the. beginning 
be. kept near the abdomen, till the point has 
reached the angle of the fymprryfis pubis. 
The fame method like wife, mutatis mutandis* 
may be followed, if the patient remain in an 
erect pofture during the operation. 

I have hitherto fuppofed the furgeon to 
make ufe of a filver catheter. If he ufes a 
flexible one, covered with elafticgum, it is of 
great confequence to have the ftilet made of 
fame firm metallic fubftance, and of a proper 
thicknefs. I always make ufe of brafs wire 
for this purpofe* If the ftilet is too {lender, 
the catheter will not preferve the fame cu.rva- 
ture during the operation; and it will be 
difficult, if not impoffible, to make the point 

* Memoirs of the Medical Society, vol, 2, Art. 30. 
t Bell's Sargery, vol % p. 34. 

or 



On Retention of Urine. 385 

of the inftrument pafs upwards behind the 
fymphyfis pubis in a proper direction. If the 
ftilet is too thick, it is withdrawn with diffi- 
culty. 

When the stilet is of a proper thickness, 
this inftrument has one advantage over the 
filver catheter, which is, that its curvature 
may be increafed while it is in the urethra. 
This alteration in the fhape of the inftrument 
is often of great ufe when the point approaches 
the proftate gland. The advantage to be 
obtained by it firft occurred to me on the 
following occafion. 

CASE IL 



I was introducing the elaftic gum catheter 
in a patient whofe proftate gland was much 
enlarged, and upon whom the operation was, 
on this account, rendered difficult. Finding 
fome obftru6tion near the neck of the bladder, 
I determined to withdraw the ftilet that I 
might fee whether the urine would run off 
through the catheter. When I began to 
draw out the ftilet, holding the catheter with 
my left hand, I rather repreffed the inftru- 
3«ent, and was agreeably furprized to find, 

C Q that 



3$6 On Retention of Ueine. 

that as I drew out the flilet the catheter 
paffed into the bladder. 

This accidental fuccefs put me upon con- 
fidering the effeft produced by withdrawing 
the ftilet, and I immediately perceived, that 
as foon as the ftilet is moved the curvature of 
the catheter is increafed. In the operation, 
therefore, by this motion of the ftilet, the 
point of the catheter muft be lifted up, and 
will thereby be prevented from ftriking againft 
the inferior furface of the proftate gland, and 
will be dire6led into the neck of the bladder. 
This discovery has been of great ufe to me 
in many difficult cafes. It will be under- 
ftood by any one who observes the motion 
which a flexible catheter makes upon with- 
drawing the ftilet*. The effe6l, however, is 
loft, if the ftilet be too (lender ; for in that 
cafe it is rendered ftraight by the a6t of with- 
drawing it, and confequently it cannot in* 
creafe the curvature of the catheter. 

There is another method of introducing 
the elaftic gum catheter, which fometimes 
anfwers very well, though it will not always 

* The effecl: of withdrawing the ftilet in part will 
be fully underftood by a view of the fecond figure in 
plate vii. The dotted lines reprefent the curvature 
v/hich the catheter takes in the a& of withdrawing it. 

fucceed. 



On Retention of Urine. 387 

fucceed. It is this. Take a catheter which 
has acquired a confiderable degree of curva- 
ture and firmness, from having lain by for a 
long time with a curved ftilet in it*. Intro- 
duce this, without the ftilet, with its con- 
cave fide towards the abdomen; observing 
the caution above given, to avoid pufbing 
on the point of the instrument, when it has 
arrived at the fymphyfis of the pubis, until 
its handle is deprefled into a horizontal pofi- 
tion. If the urethra has not been injured, 
and is in a moift ftate, this method often 
fucceeds ; but chiefly after an elaftic catheter 
has been kept for fome days in the urethra. 
Cases occur, where a frequent extraction of 
the urine is neceflary, and where the furgeon 
is at fuch a diftance from his patient as to be 
unable to give a frequent attendance. Under 
thefe circumftances, if the patient cannot be 
removed, we are under the necefiity of leav- 
ing a catheter in the urethra, until the me- 
thod laft defcribed can be performed with 

* A catheter, which has acquired the exact form of 
the urethra, would be preferable; but fuch an one cannot 
always be procured. 

The exact form of an old flexible catheter, which had 
lain a confiderable time in the urethra, and which had 
fo much rigidity as to retain its form after it was with- 
drawn, is given in plate vii. fig. 1 . 

c c 2 eafe-, 



388 On Retention of Urine. 

eafe. It may then be committed to the care 
of a dextrous and intelligent fervant, or even 
of the patient himfelf. 

Whatever method of performing this oper- 
ation is purfued, the catheter mould be in- 
troduced with the greateft gentlenefs. When 
any obftruction occurs, the defign of the fur- 
geon ihoulcl be to evade rather than overcome 
it. Unfuccefsful attempts may render a cafe ex- 
tremely difficult, which was not fo before. I wifh 
to imprefs upon the mind of my reader, that a 
moderate force, improperly directed, is capa- 
ble of injuring the urethra in fuch a manner, 
as to render the operation almoft (and without 
a juft knowledge of the injury, altogether) 
impracticable. It muft be obvious to every 
furgeon, that long continued or violent at- 
tempts, have a tendency to increafe the in- 
flammation of the urethra. But the accidents 
to which I mean particularly to direct the 
attention are, the formation of a kind of 
pouch in the urethra, and the laceration of 
its membranous part. I mail relate an in- 
ftance of each of thefe, and defcribe the me- 
thods ufed to furmount the difficulty which 
they afforded to the introduction of the 
catheter. 

CASE 



On Retention of Ueine. 389 



CASE III. 

I was confulted for a gentleman advanced 
in years, who laboured under a retention of 
urine, attended with much fever, and pain 
in the hypogaitrium. His furgeon had re- 
peatedly drawn off the urine; but could not 
any longer introduce the catheter, on ac- 
count of an obitruction in the moft depending 
part of the urethra, in its paflage through the 
pelinaeum. Before I made any attempt to 
introduce the catheter, I gave the patient, 
with the concurrence of the phyfician and 
furgeon who were attending, fifty drops of 
tincl. opii, and put him into a warm femicu- 
pium. As he was now much reduced, and of 
a gouty habit, bleeding was not ufed. As 
foon as he was taken out of the warm bath, 
I placed him in the pofition above defcribed, 
and attempted to introduce the catheter with 
its convex fide towards the abdomen. When 
the point of the inftrument arrived at the 
loweft part of the urethra, I made the turn 
as ufual, but could not * elevate the point 
behind the fy mphyfis pubis. The urethra 
feemed to be completely obftrufted, as if it 
had terminated at the part I have mentioned, 

C c 3 I had 



390 On Retention oe Urine. 

I had no reafon to think that the urethra was 
lacerated, as the obftrufted. part felt fmooth; 
but I apprehended that a kind of pouch was 
formed there, (by the dilatation of fome crypta 
of the urethra, or in fome other way) which 
a filed as a valve in the canal. As in all 
the attempts to introduce the catheter its 
convex fide had been directed towards the 
abdomen, I thought there was reafon to 
conclude, that this valve was formed in the 
inferior fide of the urethra, I judged, there- 
fore, that the moft probable method of e>a* 
ding the difficulty would be to keep the point 
of the catheter, from its first introduction, 
as clofe to the fuperior fide of the urethra as 
poffible. I had before varied the direction of 
the Inftrument without fuccefs, and was now 
convinced, that I could not keep its point 
in clofe contact with the fuperior fide of the 
canal, unlefs the concave fide of the catheter 
was turned towards the abdomen. An at- 
tempt made in this manner prevented the 
point of the inftfument from entering the 
pouch formed in the urethra, and enabled 
me to reach the bladder. The catheter, 
which was a flexible one, was retained in the 
Urethra; and by the afiiftance of gentle lax- 
I atives, 



On* Retention of Urine. 391 

atives, with cooling and demulcent medicines, 
and a proper diet, our patient recovered. 

The greatest impediment to the introduc- 
tion of the catheter (in cafes of Ample reten- 
tion of urine) arifes from the laceration of the 
membranous part of the urethra, when the 
point of the inftrument has pafled through 
it, between the bladder and the refitum. I 
am not aware that I have ever met with a 
cafe, in which the urethra was perforated 
between the bladder and the offa pubis; nor 
do I think fuch an accident is likely to hap- 
pen. Many authors have given cautions 
againft injuring the membranous part of the 
urethra; but I do not recolleQ: any one, ex-* 
cept Mr. Bromfeild, who has fpoken of this 
injury as a cafe which he had often met with. 
Mr. B. fays,* " I have feeufeveral injiances, 
6 where, from a flit having been made through 
c that part of the urethra by the inftrument, 
1 and in order to prevent future fuppreffions, 
6 bougies have been ufed ; the confequence 
6 was, that the bougies finding a readier 
c paffage through the flit, than into the 
6 neck of the bladder, a falfe route was ob- 
6 tained. Three inftances of which I lately 

* Chirurgical Obs. vol. 2. p, 302. 

C C 4 " faw/' 



392 On Retention" of Urine.' 

<\ 

66 faw." He then relates the cafe of a patient, 
who had been repeatedly fearched for the 
ftone by himfelf, and another eminent fur-* 
geon, neither of whom could ever make the 
found pafs into the bladder, on account of a 
perforation in the membranous part of the 
urethra, betwixt the bladder and the re&um, 

I am now fully perfuaded, that this acci* 
dent occurs more frequently than is commonly 
imagined; that it may happen in the hands 
of a furgeon accuftomed to introduce the ca^ 
theter, and when no great force has been 
xifed ; and that it always renders the operation 
difficult, and fometimes impracticable to 
thofe who are not aware of the nature of the 
difficulty which they have to encounter. 

And here I mull confefs, that it was an 
error in my own conduct which firft led me 
to confider this fubje6l with peculiar attention, 
and which has fince- enabled me to preferve 
the life of fome of my fellow creatures. 

A little boy was brought to me about 
thirty years ago, who had fymptoms of a 
ftone in the bladder, I had not at hand ^ 
found fmall enough to enter his urethra, ex^ 
cept one which had its point fomewhat coni-* 
cal, I had then been much accuftomed 
to introduce the found and catheter, and 



O^r Retention of Urine. 393 

was not confcious of ufing any improper force 
at this time. However, when the instrument 
had patted to a fufficient extent, I found 
reafon to fufpeet that it was not in the blad- 
der. Upon introducing my finger into the 
rectum, I was furprized to feel the found fo 
diftinclly through the coats of the inteftine, 
as to leave no doubt that I bad perforated 
the membranous part of the urethra betwixt 
the proftate gland and the re6tum. I imme- 
diately withdrew the found, and difmiiied 
the boy for that time, who fuffered no other 
inconvenience from this accident than a little 
fmarting for a few days upon making water. 

This injury, arifes chiefly, I apprehend j 
from the method (which, as far as I have 
feen, is not an uncommon one) of pufhing 
forwards the catheter before its handle has 
been depreffed. By this method, the courfe 
of the inftrument crofles that of the urethra; 
and the point of the catheter, preffing againft 
the pofterior fide of the membranous part of 
the urethra, is eafily forced through the coats 
of that canal, The want of due curvature 
in the catheter, and of fufficient bluntnefs in 
its point, greatly contribute 10 facilitate this 
injury. 

When 



394 On Retention of Urine. 

When the membranous part of the urethra 
has been pierced, the point of the inftrument 
paffes more readily into the wound, than into 
the bladder. For the wound being made 
near the proftate gland, where an elevation 
of the point of the inftrument is required ; it 
becomes very difficult to avoid the aperture, 
and purfue the natural courfe of the canal. 
The following cafe will point out the method 
which I have ufed to enfure fuccefs in the 
operation, when rendered difficult by this 
accident. 

CASE IV; 

In January 1787, I was defired to vifit 
an old gentleman forty-five miles from Leeds, 
who was labouring under a retention of urine, 
and could not any longer be relieved by the 
furgeon who attended him. I arrived at 
three in the morning, and found the phyfician 
and furgeon waiting my arrival. The latter 
gave me the following hiftory of the cafe : 
That Mr. M. having been seized with a re- 
tention of urine betwixt three and four weeks 
before, he (the furgeon) had extracted the 
urine without difficulty, and had repeated 

the 



On Retention of Urine. 395 

the operation twice, and fometimes thrice in 
the day, during three weeks. He then began 
to find fome obftruction in the urethra near 
the proftate gland, which increafed at every 
operation, till he was unable any longer to 
introduce the catheter. The patient had now 
been three days without relief, and the blad- 
der was largely diftended. Upon introducing 
the catheter, its point, when it had ap- 
proached the proftate gland, paffed into a 
fubftance that felt ragged and fibrous. I had 
no doubt, from this fenfation, that the pot- 
ter ior fide of the urethra was perforated. 
The object now was to keep the point of my 
catheter clofe to the anterior fide of the 
urethra, as it pafled through its membranous 
part, that I might avoid the wound, which 
the point of the inftrument entered with rea- 
dinefs. The ftilet of my flexible catheter, 
which I firft ufed, was rather too weak; I 
therefore bent a filver catheter, at the diftance 
of about an inch from its point ; that having 
a greater curvature than ufual in that part, 
I might be enabled to keep the point of the 
inftrument more clofely in contaft with the 
anterior part of the urethra, and thereby 
pafs over the wound made in the pofterior 

fide 



396 On Retention of U'fcisrife; 

fide of that canal. This method, affifted by 
the mode of introduction already defcribed, 
-was attended with fuccefs, and I drew off 
about four pints of urine. - 

As I could neither ftay with my patient, 
nor leave him with propriety in this fituation, 
I thought it neceffary to introduce ail elaftic 
gum catheter, which might remain in the 
urethra till the wound ftiould be healed. I 
procured fome brais wire of a proper thick- 
nefs, with which I made a ftilet; and having 
given it the fame curvature as that of the 
filver catheter with which I had extracted the 
urine, I introduced it about four hours after 
the former operation, and fixed it by tying 
it to a bag trufs put upon the patient. 

It is remarkable, that I drew off a quan- 
tity of urine from the bladder that . had been 
emptied but four hours before, nearly equal 
to that which was found in the bladder, after 
the retention had fubiifted three days. 

The life of my patient was preferved at this 
time ; but the catheter was fuffered to remain 
in the bladder. After fome weeks an inflam- 
matory affection enfued, which brought on a 
difcharge of purulent matter, and the patient 

died 



On Retention of Urine, 397 

died heftical about fix months after my 
viiit.* • 

I could relate other cafes of a fimilar na- 
ture which have occurred to me; but as 
I have fucceeded with the aiTiftance of an 
elaftic gum catheter, either by withdrawing 

* The following accounts, which T received from Mr. 
M.'sfurgeon, iliew the progrefs of the complaint after 
my viiit. 

" Feb. 19th, 1787. 

e< Our patient, Mr. M. feemed to enjoy a good ftate 
u of health from Jan. 4th, to Feb. 4th, when he had a 
4i difcharge from the urethra fimilar to that of a gleet, 
" attended with a little inflammation of the glans penis, 
" He has alio for this week pait found a little uneafinefs 
" when he wanted to have his water drawn off." (I 
fuppofe by taking the cork out of the flexible catheter, 
which I had left in the urethra.) 

" July 1st, 1787. 

** Mr. M.'s complaint ftill continues. The irrita- 
■* tion is so great as to require the water to be drawn off 
** every two hours. For fome time pail there has been 
" a quantity of mucus and pus rather fetid difcharged 
** with the water, which has been fo corrofive as to 
" deftroy the inftrument you left, and alio one that 
" was introduced the 27th ult. For the lail fortnight 
fC the difcharge has been lefs oifenfive, but mixed with 
■* blood, which alarms him much. 

u The flexible catheter is conftantly withdrawn, 
u when Mr. M. jun. is at home, except in the night, 
" when his father dare not ileep without it. He" (the 
fon I fuppofe) " can introduce the flexible one very 
" well, but cannot the common one/- 



the 



398 On Retention of Urine. 

the flilet in part at the moment when I 
wiftied to increafe the curvature of the cathe- 
ter, or by giving the inftmment a confidera- 
ble degree of curvature previoufly to its in- 
troduction, I shall not trouble my reader 
with a more particular relation. 

In one cafe, where the urethra had been 
injured near the fymphyfis pubis, bjr a violent 
contuiion, (my patient's horfe having fallen 
backwards upon him, and ftruck the parts 
with the pommel of the faddle) I drew off 
the urine with a filver catheter of unufual 
thicknefs, after I had failed with inftruments 
of a fmaller bore. In this cafe I fufpecled a 
rupture of the urethra, and was obliged to 
elevate the point of the catheter with my 
finger in the re6lum, before it would pafs 
the injured part. I was alfo obliged to ufe 
repeated bleeding, purgatives, the warm bath, 
and large dofes of opium, before I could fuc- 
ceed in the introduction. After the firft in- 
troduction I ufed the elaftic gum catheter, 
in the manner above directed. 

The invention of the flexible catheter, co- 
vered with elaftic gum, has been of great 
utility in this important operation of furgery; 
but it is a queftion not yet decided, whether 
the cure is more promoted by leaving the 

catheter 



On Retention of Urine. 399 

catheter in the urethra until the patient re* 
gain the power of expelling his urine, or 
by extracting the urine twice a clay, and 
withdrawing the catheter after each opera- 
tion. 

As far as it concerns the removal of the 
inflammatory fymproms, I do not fee that any 
general rule can be laid down. I have feen 
fome patients who could not bear the cathe- 
ter to remain in the urethra without great 
uneaiinefs; while others have recovered from 
the firft inflammatory ftage of the difeafe, 
even in bad cafes, without appearing to be 
hurt by wearing the catheter conftantly. 
Yet, upon the whole, I prefer the removal 
of the catheter after each operation, in all 
ordinary cafes; and now always ufe this me- 
thod, when my patient is near, and under 
my own immediate care. 

With regard to the refpective merits of 
thefe methods, as promoting the complete 
cure of the difeafe, my opinion feems at pre- 
fent to be decided. I have tried thefe dif- 
ferent methods fo often, and in cafes fo near- 
ly fimilar, that I can fcarcely entertain a 
doubt, that a perfon regains the power of 
expelling his urine much fooner when the 

catheter 



400 On Retention of Uhine. 

catheter is withdrawn after each operation, 
than when it is left in the urethra* 

The beft method of retaining the catheter 
in the urethra, which I have tried, is the 
following. To each fide of a bag trufs, made 
with a ftrap to go over the penis, I few on 
three fmall loops of tape. The lower loops 
are fixed to the middle of the trufs; the two 
higher to the extremities of that part which 
goes over the penis. When the trufs is put 
on, and a piece of very narrow flat tape is 
put through the rings of the catheter, I put 
the oppolite ends of the tape firft through the 
lower loops on each fide, and then through 
the middle loops; and after carrying the 
ends of the tape acrofs each other beneath 
the penis, and making them pafs through 
the higher! loop on each fide, I tie them 
above the penis upon the middle of the pubes. 
By this method the catheter is kept steady, 
if the patient is moderately cautious. To 
prevent the extremity of the catheter from 
catching hold of the patient's clothes, I fome- 
times apply a ~J~ bandage over the bag trufs 
and catheter, or fallen the middle ftrap of 
fuch a bandage over the fiifpenfory, by which 
method the catheter may be kept quite fe- 
cure. 

I have 



On Retention of Urine. 401 

I have already mentioned fome circum- 
fiances, which have a tendency to miflead 
the medical practitioner, in the treatment of 
the difeafe which I am now conlidering ; and 
it may be of ufe to add a few obfervations 
on thefe fources of deception. 

CASE V. 

In the early part of my practice, about 
forty years ago, I was attending Mr. Hep- 
worth, an elderly man, who laboured under 
a retention of urine. I had drawn off his 
water morning and evening for a few days, 
when I was informed, that he had regained 
the power of relieving himfelf. About a pint 
of urine was {hewn to me, as the quantity 
which he had made in the courfe of the night 
with a natural ft ream. I began to apprehend 
that my attendance would be no longer ne- 
ceflary; but as he ftill complained of the 
fame uneafinefs in the hypogaftrium, I ex- 
amined the ftate of the abdomen, and was 
furprized to find the bladder diftended as 
much as it had ufually been before his urine 
was extracted, and the operation was found 
ro be as neceffary as it had been before. 

This cafe taught me the necenity of con- 

D d Uniting 



402 On Retention of Urine. 

tinuing to introduce the catheter, till it clearly 
appears, that the patient can empty his 
bladder by the natural efforts. 

CASE VI. 

About two years ago I was defired to vifit 
a patient early in the morning, whom I had 
repeatedly attended on account of a retention 
of urine. He complained of confiderable pain 
in the hypogaftriurn, though he had made 
two quarts of urine in the courfe of the night. 
I found his bladder diftended, and drew off 
about a pint of urine, which he had not been 
able to expel. 

When there has been a neceffity for ex- 
tracting the urine by the catheter during 
two or three weeks, the power of expelling 
it voluntarily generally returns by degrees. 
The propriety of omitting the operation is not 
to be determined by the quantity of urine 
which the patient expels, but by the power 
of emptying the bladder. 

Another fource of deception is the invo- 
luntary difcharge of urine, which fometimes 
fucceeds a retention that is not relieved by 
the catheter. This is not fo frequent an 
occurrence as the former; but it is highly 

dangerous. 



On Retention of Urine. 403 
dangerous, when the proper means of relief 
are neglected. 

CASE VII. 

I was defired to vifit Mr. Lawn, of Hunflet, 
riear Leeds, an old man, who had laboured 
tinder an incontinence of urine about four- 
teen days. Upon inquiring into the manner 
in which this difeafe commenced, I found that 
it had been preceded by ail inability of ex- 
pelling his urine. This circumftance led me 
to examine the abdomen, when I found the 
bladder diftended greatly, and giving pain 
when preffed upon. I extracted the urine 
by means of the catheter; but notwithstand- 
ing the temporary relief which this operation 
afforded him, he died the following day, 
though the complaint in his bladder feemed 
to be the only difeafe which had aifecled 
him. 

CASE VIIL 

May 17th, 1798, I vifited-Mr. B. aged 
fixty-feven years, who lived about fixteea 
miles from Leeds, and laboured under aa 
incontinence of urine. 

About a fortnight before I faw him, he 

T> & Z had 



4(H On Retention op Urine. 

had been feized with an inability of difcharg- 
ing his urine freely, attended with consider- 
able pain in the hypogaftrium, In the courfe 
of two or three days he loft entirely the power 
of expelling his urine by any voluntary ef- 
forts, and it began to flow from him invc-r 
luntarily, and inceffantly. 

I found him in a very weak ftate. His 
tongue was white, and rather dry. His pulfe 
frequent. His thirft confiderable. He was 
reftlefs, being able to get very little fleep, 
and having a conftant uneafinefs in the abdo- 
men. The bypogaftrium was enlarged, and 
felt very fore when preiied upon. The blad- 
der was in a diftended itate, and rofe fome- 
what higher than the navel. The penis was 
fore from the conftant flow of urine. 

I had fufpected the nature of his coin plaint, 
from an imperfect account which I had re- 
ceived from a friend of the patient, wh6 
came to defire my attendance; and in confe- 
quence of this fufpieion, I had brought with 
me a flexible catheter, and a bag-trufs. 

I immediately extracted his urine* though 
with fome difficulty, and left the catheter in 
the urethra, fecured by means of the bag- 
trufs, in the manner above deicnbed. 

He begged that he might have fomething 

to 



On Retention of Urine. 405 

to drink which was cooling, as his furgeon had 
confined him chiefly to gin and water for be- 
verage, to enable him to expel his urine more 
freely. I gave him a balbn full of milk, 
which he drank with the greateft pleafure. 
I wifhed to have brought him to Leeds with 
me, but he thought himfelf unable to bear 
the journej', and was defirous to remain at 
home. I advifed him to let off the urine 
every four or five hours. 

27th, I vilited Mr. B. again, drew' out 
the catheter, and after cleaning it, and re- 
moving the calculous matter which adhered 
to its extremity, I replaced it. He could 
not yet expel his urine. 

A week after this vifit Mr. B. was brought 
to Leeds. I waited a few r days after his arri- 
val before I withdrew the catheter; but did 
not observe any natural efforts which could 
enable him to expel his urine. On the 11th 
day after the laft introduction I took out the 
catheter, the extremity of w r hich, for the 
fpace of an inch, was curiouily encruited with 
calculous matter. 

I now extracted his urine twice a day, with- 
drawing the catheter after each operation. 
I attended him at feven in the morning, and at 
nine in the evening, as there was always a 

d d 3 more 



406 On Retention of Urine. 

more copious fecretion of urine in the night- 
time than in the day. White matter, of a pu- 
rulent appearance, flowed from the bladder 
with the laft portion of urine. 

As his nights were not paffed comfortably, 
and as the painful defire to make water re- 
turned fometimes very early in the morning, 
I gave him for feveral nights a bolus at bed 
time with calomel gr. v. and opium gr. j. 
which procured comfortable reft, and feemed 
to haften on the power of expelling his urine; 

At the expiration of a week, after I had 
begun to introduce the catheter twice a day, 
he found a little involuntary difcharge of urine 
in the morning as he lay in bed, and could 
then expel a fmall quantity by the natural 
efforts. At this time he rofe to make ufe 
of the chamber-pot, but no fooner did he 
increafe his efforts, than the flow of urine 
ceafed. I advifed him to lay fome pieces of 
blanket fo as to receive his urine when it began 
to flow involuntarily, and to ufe the moft 
gentle efforts as he lay upon his fide, when 
the involuntary discharge ceafed. By this 
method the urine flowed in greater quantity, 
than by ft raining over the chamber-pot. 

The purulent appearance of the laft por- 
tion of urine ceafed gradually, after I had 

begun 



On Retention of Urine. A07 
begun to extract his urine twice a day; and 
at the expiration of iixteen days he needed 
no longer the affiftance of the catheter. 

CASE IX. 

One evening I received a rneffage from a 
young gentleman, defiring my attendance 
upon his father the next day. The rneffage 
was accompanied with the following letter : 
" My poor father has been exceeding ill for 
" the laft fortnight. He was feized about 
" that time with considerable pain, which 

" Dr. and Mr. — - — who attend him, 

" think proceeded from fome diforder in the 
" urinary veffels. It was attended at firft 
" with a fuppreffion of urine, but has fince 
" changed to an involuntary difcharge, which 
" occaiions great pain and irritation." 

I went over to— — the next day, and took 
a catheter along with me, apprehending that 
the difeafe might prove to be a retention of 
urine. As foon as I was feated by the lide 
of my patient's bed, I examined the hypo^ 
gaftrium, and found the bladder forming a 
hard tumour, which extended rather higher 
than the navel. 

I defired that the furgeon might be fent 

D r> 4 for 



408 On Retention of Urine, 

for immediately, and comforted my patient 
with the profpecl of fpeedy relief. 

The difeafe had now fubfifted fixteen days, 
and had begun in the following manner. Mr. 

- was awaked about two o'clock in the 

morning, with a painful motion to make 
water, a complaint to which he was fomewhat 
liable; but at this time he could difcharge 
no urine. He remained in this diftreffing 
ftate for fome hours; but in the courfe of the 
day (he could not recollect at what hour) the 
urine began to flow involuntarily. This eva- 
cuation, however, afforded him but a fmall 
degree of relief. He continued to have a con- 
ftant uneafinefs, attended with great reftleff- 
nefs; fo that from the commencement of the 
attack his repofe feldom continued above an 
hour at one time. He was feverifh. Various 
remedies had been adminiftered; and before 
mv arrival, the fever had abated in fome 
degree, and the pain was fomewhat diminifh- 
ed. His tongue had become clean. 

As foon as the furgeon arrived, the cathe- 
ter was introduced, and four pints of urine 
were extracted. This was not high coloured, 
as is generally the cafe in a complete reten- 
tion. I attributed its palenefs to the conftant 
1 influx 



On Retention of Urine. 409 

influx of urine from the kidnies, and the con- 
stant flow from the urethra. 

I never knew a patient appear to receive 
fo little relief by the extraction of fo large a 
quantity of urine. He was very weak, and 
continued to be reftlefs and uneafy. 

As this operation did not enable Mr. 

to expel his urine by the natural efforts, it 
was extracted again the following morning, 
and then exceeded fomewhat four pints in 
quantity. In the evening of the fame dav, 
the urine drawn off was about a pint and 
half. 

On the third day an elaftic gum catheter 
was left in the urethra, and fecured by means 
of a bag-trufs. 

Four days after I had left my patient, I 
received a meffage to inform me, that the 
catheter had flipped out of the urethra. The 
meflenger brought me the following account 
from the phyfician who was attending. 

" Some days ago the urine was very fetid, 
" and alkalefcent, and at the bottom there 
was a confiderable quantity of fanious 
mucus, which laft has continued to appear, 
but the urine diminishes in quantity. Laft 
night not more than from three to five ounces 
" was discharged at a time, and that much 

" loaded 



u 

u 

Li 

u 



66 



410 On Retention of Urine. 

loaded with bloody mucus. He has alfo 
complained of fmarting and burning latter- 
ly when it was drawn off. The pulfe has 
ftood at ninety day after day." 
I fet off immediately to vifit Mr. — ■ — ■* 
but before my arrival the furgeon had re- 
placed the catheter. The urine which was 
let off after this replacement was not more 
tinged with blood than it had been the pre- 
ceding day; but at five in the afternoon, more 
than half the quantity of fluid which ran 
through the catheter was pure blood, and 
coagulated as it flowed. The quantity of 
blood which flowed at this time was about 
four ounces. The blood was florid, as if re- 
cently extravafated. Upon inquiry, I found 
that the belt of the bag-trufs had been fuf- 
fered to Aide down below the hips, and had 
confequently drawn out the catheter. 

I put on a frefh fufpenfory ; added (houlder 
ftraps to it, and alfo a broad piece of Angle 
calico, which was put on as a | bandage 
over all, for the purpofe of covering the ex- 
tremity of the catheter. This additional part 
was fattened to the belt behind with fmall 
buttons, and was pinned before; fo that it 

might be readily removed when Mr. 

had Qccafion to ufe the night-chair. 

Our 



On Retention of Urine. 411 

Our patient was evidently funk with the 
haemorrhage. A cold fweat lay upon his 
arm the remainder of the day, and his pulfe 
was more feeble than ufual. 

We had directed Mr. to abftain from 

wine, or to take very little, on account, of 
the tender ftate of the bladder; but the 
degree of debility which fucceeded the haemor- 
rhage induced us to change the plan of diet. 
We now directed him to drink half a pint of 
wine in the courfe of the day, partly old 
hock, and partly red port. We ordered the 
following medicines for him : 

R. Decoct. Cort. Per. 3jvij. 

Tinft. fimp. ^ j- mifce fumat 

#&€£. iij fextis horis. ^ € 

R. Aq. pura3 £x. fpt. cinnamomi. 

Syr. fimp. aa 5J. tinft. ferri muriat. g tts 
xx. mifce fiat hauftus fextis horis 
fumendus, 

Thefe medicines were to be taken alter- 
nately every three hours. 

The next day Mr. feemed much re- 
cruited by the change of diet, and the me- 
dicines. His cold fweats were gone off, and 
his pulfe in the afternoon, when I left him, 
was at eighty-eight, He was able to walk 
.a little about his room. His urine was highly 

tinged 



4018 On Retention op Urine/ 

tinged with blood of a dark colour, but n® 
frefh blood appeared. 

Dr. — informed roe by letter, that on 

the third clay after this vifit, a feparation in 
the urine appeared, the dark-coioured fedi- 
roent falling to the bottom. After that day 
there was no fe.diment, but the urine conti- 
nued clear, and without fetor. 

At the expiration of. a fortnight I paid a 

third vifit to Mr. . His urine had ftill 

continued clear, but was rather high coloured. 
Pulfe feventy-eight. Tongue clean and moift. 
Appetite good. Strength encreafed. 

The catheter was removed, that a trial 
might be made whether our patient had re- 
gained the power of expelling his urine.. The 
inability ftill remained, and the catheter was 
replaced. 

At the expiration of a week after my laft 

vifit, Mr. came to Leeds. The retention 

of urine had now fubfifted forty-feven days, 
during thirty-one of which the catheter had 
remained in the urethra, except when with- 
drawn for the purpofe of trying our patient's 
ability of relieving himfelf. 

Mr. was not now fo free from inflam- 
matory fymptoms as when the catheter Was 
laft withdrawn. His urine had a higher 

colour, 



On Retention of Urine. 413 

colour, and an offenfive fmell. Some flukes 
of purulent mucus were difehargecl along with 
it ; and he felt pain in his bladder when the 
laft portion of urine was flowing through the 
catheter. I was apprehenfive that his diet 
had been too generous, with the view of en- 
creating his ftrenirth. 

I tried the effect of extracting his urine 
every twelve hours, without leaving the in- 
ftrument in the urethra. But the fecretion 
of urine was ufually fo copious in the night- 
time, that he was in a very painful ftate for 
fome hours before the appointed time arrived 
for extra6tins: his urine in the morning;, not- 
withftanding he ufually took two grains of 
opium at bed-time. I determined, therefore, 
to leave the catheter again in the urethra, 
and try by a ftrict regimen, and other ap- 
propriate means, to remove the inflammatory 

fymptoms which ftill remained. Mr. 

left off' the ufe of flem meat and wine, took 
gentle laxatives occahonaliy, and drank the 
lac amygdala?, with mucilage of gum arable 
added. 

I removed the catheter after it had re- 
mained about a fortnight in the urethra; 
and as my patient could not yet relieve him- 
felf, I thought it belt to extract his urine 

every 



414 On Retention o£ Urin£. 

every eight hours, (viz. at ten in the evening* 
at fix in the morning, and at two at noon) to 
prevent too great an accumulation in the 
bladder. This method was attended with 
fuch fuccefs, that at the expiration of a 
week he began to expel a confiderable part 
of his urine by the natural efforts. I conti- 
nued to introduce the catheter once or twice 
a day, for a few days* and then once in two 
or three days, till I found him capable of 
emptying the bladder. He had received fo 
much benefit from the opiate, that he con- 
tinued to take a fingle grain every night at 
bed-time. 

After remaining two or three weeks longer 
at Leeds, to try the effecl of exercife, and 
his ufual mode of living, he returned home 
perfectly free from the diforder, which had 
afflicted him nearly three months, and which 
had repeatedly been attended with very 
dangerous fymptoms. 

REMARKS. 

I have related this cafe at fome length, as 
it affords much inftruclion in the manage- 
ment of this important difeafe. 

1 . We fee how foon a complete retention 

of 



On Retention of Urine. 415 

of urine may change to an inyoluntary dif- 
charge, the bladder ftill remaining in a dis- 
tended ftate. I queftioned Mr. — — very 
ftriftly refpecling the time at which the in- 
voluntary emiffion of urine took place; but 
he could not recollecl; the hour exactly. The 
information which I received from thofe who 
attended him led me to conclude, that the 
total fuppreffion had not continued above 
twelve hours before the involuntary difcharge 
commenced. This fpeedy alteration in the 
appearance of the difeafe, caufed the antece- 
dent fuppreffion to be overlooked; and led 
to an omiffion of the appropriate remedy. 

2. I have frequently obferved, as occurred 
in this cafe, that a copious fecretion of urine 
immediately fucceeds the firit extra6tion, 
when the retention has not been fpeedily 
relieved. The quantity of urine extracted 
after twelve hours exceeded that which had 
been drawn off at the firft operation by 
about half a pint. In Mr. M/s cafe (Cafe IV.) 
the quantity of urine extracted after the (hort 
interval of four hours, was nearly equal to 
that which had been previoufly extracted 
after a complete retention had fubfifted for 
three days. 

3. In extracting the ursine regularly night 

and 



i\6 On Retention of Urine, 

and morning, with the exaft interval of 
twelve hours, I have often obferved, that 
the quantity of urine fecreted in the night, 
has exceeded that fecreted in the day. This 
occurred in an unufual degree in the prefect 
cafe. The quantity of urine drawn off in the 
evening feklom amounted to a pint, and 
fometimes did not exceed half a pint; while 
the fecretion in the night-time was often more 
than two quarts. Nay, it happened fome- 
times, that Mr. — difcharged three, or 
four pints in the violent {trainings which 
accompanied this abundant no6turnal fecre- 
tion, while a painful retention continued, 
fo that I drew off an additional pint in th& 
morning. 

4. This cafe fliews,- as clearly as a fingle one 
can mew, that a patient fooner regains the 
power of emptying his bladder by the natural 
efforts, when the catheter is withdrawn after 
each extraction, than when it is fuffered to 
remain conftantly in the urethra. 

To the above remarks I have the pleafure 
to add, that the gentleman whofe cafe is laft 
related, has been more free from the at- 
tacks of painful miclurition fincehis recovery, 
than he had been for a confiderable time 

before. 

I cannot 



On Retention of Urine. 417 

I cannot conclude thefe obfervations, with- 
out urging the propriety of an early intro- 
duction of the catheter in this difeafe. Delay 
is not only fruitlefs, in general; but alfo 
renders the operation more dangerous, as 
well as more difficult, and ufually protra&s 
the completion of the cure. Befides, the 
great degree of inflammation which the 
bladder fuffers, when the extraction of the 
urine is long delayed, brings on fometimes a 
fuppuration in the part. I have feen many 
inftances of this. The retention has indeed 
been cured, but a difcharge of purulent mat- 
ter has fucceeded, and the patient has died 
tabid. If the circumftances of the cafe re- 
quire bleeding, purging, the injection of a 
^clyfter, or the ufe of a warm bath; a delay 
for thefe purpofes may be beneficial: but 
delay mould only be considered as prepara- 
tory to a more fafe introduction of the ca* 



E 23 



[ *18 ] 

PLATE VII. 

Fig. 1. reprefents the exact form of an old- 
flexible catheter, which had lain a consider- 
able time in the urethra of a male patient/ 
I have obferved the fame form in other ca- 
theters, which had been fuffered to remain 
in the urethra, and which had firmnefs enough 
to retain that degree of curvature which they 
had acquired in the urethra. 

Fig. 2. fhews the effecT; which is produced 
In a catheter by withdrawing the ftilet, if it 
is fufficiently firm. The figure in outlines, 
which is neareft to that of the inferior cathe- 
ter, was taken when the ftilet had been with-* 
drawn about half an inch. 



To /iter l'ft<;< 418, 




PL. 8. 



FiQ. 2 



[ 419 ] 



CHAP. XI. 

On the Cure of the Procidenti. 
; Attr in Adults. 



CASE 1. 



IN autumn 1788, Mr. W. of Hull, con- 
fulted me on account of a complete and moll 
troubleibme procidentia ani, which came on 
whenever he had a {tool, and continued for 
ibme hours; the gut gradually retiring, and 
at laft difappearing, until he had occafion to 
go again to the vault. The returns .of this clil- 
eafe were invariable, and fo diftreffing, when 
they happened m the day-time, that he had 
brought himfelf into the habit of having a 
ftool every other evening, a little before bed- 
time. After each ftool he ufed to place him- 
felf in a chair, and make a gentle preffure 
upon the prolapfed part, which afforded him 
a little relief: he then lay down in bed; and, 
the inteftine by degrees regaining its natural 
fituation, he found himfelf in the morning 
free from the prolapfus. While the inteftine 

e je 2 remained 



420 PROCIDENTIA ANI. 

remained prolapfed, there was a copious dif* 
charge, from the part, of a ferous and mu- 
cous fluid mixed with blood. " 

Although he had no pain, nor other incon- 
venience, during the intervals of thefe at- 
tacks, yet the anus did not return to its 
natural ftate. It was conftantly furrounded 
by a thin pendulous flap, which was formed 
by the integuments, jand- hung down to the 
extent of three-fourths of an inch in general. 
The anus was alfo furrounded with feveral 
foft tubercles of a bluifti colour, which were 
fituated at the bails and interior part of the 
pendulous flap. Thefe tubercles had the 
fame appearance as thofe which often remain 
in perfons who have been frequently affli6ted 
with the external piles ; and were evidently 
formed by the extremity of the re&um. 

Mr. W. gave me thehiltory of hisdiforder; 
which he afterwards wrote down, as follows : 

" When I was feven or eight years old, 
" I remember to have fuffered much pain by 
^ the bowel coming down after a ftool; but 
" 1 think this complaint did not continue 
-" long with me. From that age till about 
" twenty-two, I enjoyed an excellent ftate 
" of health, and had no appearance of any 
-' complaint in the anus; only 1 remember 

" that 



Procidentia Ani. 421 

" that. I ufed often to feel an inclination to 
" fit pretty long at the vault, \vhich I in- 
M dulged probably too much. 

" About the age of twenty -two, on going 
Cf to the vault, I for the firfb time perceived 
u that I had voided a good deal of clear blood ; 
" but do not remember that I had any pain 
M at that time. After this I was often, 
" if not generally, troubled with a little 
" difcharge from the anus, which was ufually 
" of blood. I commonly perceived fome 
" heat and uneafmefs after a ftool, and thefe 
" gradually increafed, together with a fmall 
" protuberance on the edge of the anus; 
u which laft I think I did not perceive till 
w fome weeks, perhaps months, after the 
" firft difcharge of blood. The difcharge 
" after ftool increafed by degrees, fo that 
* ; in twelve or eighteen months after the firft 
" attack I was obliged to apply linen cloths 
^ to the part affecled, 

" I was now conftrained to mention my 
" diforder, and various applications were 
" made ufe of for my relief, as the powder 
$ of nut galls mixed with hog's lard, elder 

ointment, and a folution of Roman vitriol, 

but without effect. Opening electuaries, 
* fulphur, &c, were prefcribed for me, but 

"E E 3 w tO 



422 Procidentia Ani, 

<•" to as little purpofe, the diforder ftill in- 
" creafing. After about two years, I feldom 
" parted with a ftool in lefs"time than twenty 
" or thirtv minutes: and often voided a sood 
" deal of blood. Thus I continued for feve- 
u ral years, the pain after each flool, and the 
" protuberances gradually mcreaiing, as did 
" alfo the difcharae of blood and mucus. 

" After enduring this complaint {even or 
" eight years, I applied to Mr. Sharp, an 
" eminent furgeon in London, who gave me 
" an ointment to apply after each ftool, feme 
" foapy pills to take, and recommended the 
" ufe of a ciyfter a little before going to ftool; 
" but this laft I could never effect, though it 
" was that from which he feemed to expect 
" the moft benefit. 

For many years paftl have feldom had 
a ftool oftener than every other day, and 
always with great pain after it. For two 
" or three years pall the pain has feldom 
" fubfided in lefs time than from four to fix 
" hours. In the intervals I have been able 
" to walk or ride on horfeback with eafe : 
" mid I have in other refpecls enjoyed a 
" good ftate of health, excepting fometimes 
" a deprefiion of fpirits, and more nervous 
" feelings than formerly. My legs have 






" occa^ 



Procidentia Ani. 423 , 

^ occafionally fmall fcarlet fpots upon them, 
" and are fometimes fwelled about the ancles. 

" I think it is now about fifteen years 
*' fince the firft attack of bleeding. I can- 
" not lay how long the gut has been in the 
**, habit of coming down; but I think it did 
" not come down much, if at all, when I 
<c confulted Mr. Sharp feven years ago; 
" though the pain was then quite fimilar to 
iC what it has been fince,- only it did not 
" continue fo Ions;." 

I recommended a trial of the folio wins; 
lotion, for warning the part afte6ted during 
-the ftate of prolapfus; and I alio advifed 
him to keep it applied to the anus in the 
intervals, by means of a thick comprefs fup- 
ported by the "]~ bandage. 

1$. Aq. Calcis fun p. Ibij. 
Cort. Quercus contuf. %iv. 
f. Infufum per hebdomadarn, et colaturse adde 
Spt. Vini reel. §iv. f. lotio. 

He thought himfelf for a time fomewhat 
relieved by the application : but farther trial 
fhewed, that the relief obtained was inconfi- 
derable; and that the difeafe was too obfti- 
nate to be cured by fuch treatment. 
L To obviate the bad effects which arofe 

E e 4 from 



• 424 Procidentia Ani, 

from the long continuance of the 
after each ftool, I tried to reduce the intes- 
tine foon after it came down; but the at- 
tempt gave him much pain, and afforded no 
relief. I was fatisf]ed upon the trial, that 
the reduction w&s impracticable. 

Although the prolapfed part of the intef- 
tine confifted of the whole inferior extremity 
of the reCtuni, and was of confiderable bulk; 
yet the impediment to reduction did not 
arife from the ftriCture of the fphhieier crni* 
for I could introduce my ringer with eafe duiv 
ing the procidentia : but it feemed to arife from 
the relaxed ftate of the loweft part of the 
inteftine, and of the cellular membrane which 
connects it with the circumjacent parts. 

My attempt proved vain as to its imme-» 
diate object, yet it fuggefted an idea which led 
to a perfefit cure of this obftinate diforder. 

The relaxed ftate of the part which came 
down at every evacuation, and the want of 
Sufficient ftriCture in the fphin&er ani, fatis- 
fied me, that it was impoffible to afford any 
effectual relief to my patient, unlefs I could 
bring about a more firm adhefiqn to the 
furrpunding cellular membrane, and increafe 
the proper aCtion of the fphinCter. Nothing 
feemed to me fo likely to effect thefe puiv 
pofes, as the removal of the pendulous flap, and 

the 



Procidentia Ani. 425 

the other protuberances, which furrounded 
the anus, I hoped that the inflammation 
caufed by this operation would produce a 
more firm adhefion of the re&um to the iur- 
rounding cellular fubftance; and I could not 
doubt that the circular wound would bring 
on a greater ftricture in the fnhin&er anu 
1 explained my ideas to my patient, and he 
thought it right to fubmit to the operation 
Which I propofed, 

November 13 th. After having given a 
gentle laxative, I removed with the knife 
all the pendulous flap above defcribed, and 
the moft prominent of thofe bluifti foft tu- 
bercles which immediately furrounded the 
anus. Very little blood was loft by the hi* 
cifions, 

15th. Mr. W. continued eafy; but an 
effort to go to ftool, w.hich he made this day, 
caufed a fmall part of the reftum to appear 
within the fphincter ani. I hoped that this 
prolapfed part would have gradually retired 
as it ufed to do; but, inftead of this event, 
the rectum came down in greater quantity, 
attended with much pain. I attempted to 
procure eafe by giving opiates, and applying 
fomentations, and did not immediately try 
to reduce the prolapfed part, having before 
the operation fbund fuch attempts ineffectual. 

However, 



426 ■ Procidentia Asri-. 

However, the proiapfus' continued to long, 
that the appearance of the part began to 
alter- j and I faw it would be hazardous to 
permit the rectum to remain any longer in 
this fituation, 

16th. This clay at noon I made an at- 
tempt to reduce the inteftme, and fucceeded 
with the greateft eafe. After the reduction 
Mr. W. complained of . fo much pain in the 
Jiypogajiriwn^ that in the evening I thought 
it proper to bleed him* and to purge him 
gently with the oh ricini, 

Thefe means afforded the defired relief, 
and the fucceeding evacuations by (tool did 
not again bring down any part of the reclum. 
But, as fome pain in the lower belly lit ex- 
ceeded the evacuations, I thought proper to 
reftrain this by giving an opiate. I directed 
a mild and {lender diet, the drinking of lin- 
feed tea, lac amygdala?, &c. gave a little 
cl. ricini every morning, or every other 
morning, and gave an opiate after a ftool 
had been procured. By proceeding in this 
manner for fome days, regular ftools were 
procured without any permanent inconve- 
nience. My patient recovered, very well, 
and was freed from this diftrcfiing complaint, 
which had afflicted him fo many years, 

In 



ti 



<c 



Procidentia Ani. 427 

In March 1789, I received a letter from 
Mr. W. of which the following is anextrad: 

" Dear Sir, 

" Agreeable to your kind requeft I fit 
down to inform you how I go on. For 
" forne time paft I have been very regular 
in my body, having generally had a call 
M every day, fo that I have feldom had occa* 
" lion to ufe the caftor oil. I apprehend I 
" am now nearly the fame as before the 
complaint commenced; only that I con*- 
ceive the contraction occafioned by the 
operation is fiill greater than is natural; 
" but I find very little inconvenience from 
" that, as I guard againit cofiivenefs. In 
" one inftance I am perhaps fomewhat dh> 
" ,ferent from others; that is, immediately 
" after an evacuation the lips of the anus 
" (as I conceive) contract haftily, and in that 
€f contrachon give a little fliarp pain, but it 
is over perhaps in lefs than a minute, I 
never bleed now; nor do I perceive any 
fymptoms of my old complaint, for which 
" I defire to be ever and unfeignedly thank- 
" ful. It is a. blefimg which I truft I (hall 
" never forget ." 

In May 1791, 1 had the pleafure of a yifit 

from 



4*28 Procidentia Ani. 

from Mr. W. who then informed me, that he con- 
tinued well. He faid he felt a very fmall protu- 
berance at the anus* not longer than an eighth, 
or at the mod a quarter, of an inch, when 
he went to ftool ; efpecially if he ftrained more 
than ufuab But this went away immediately 
$fter the evacuation? and gave him no trouble. 

CASE It 

Mr. K. of Wetherby, confulted me in 
October 1790, on account of a troublefome 
procidentia ani, attended with frequent bleeds 
ing, arid with the external piles. He had 
been fubjeft to difcharges of blood, at times, 
upon going to ftool, for twenty years. The 
piles had frequently burft, qiid then beconir 
ing flaccid they grew eafy, and he felt no in- 
convenience from them for a time. During 
the laft two -yeays they had continued to 
increafe in fize, and had not burft as ufual. 
They were become fo troublefome, that he 
could neither ride nor walk with eafe, 

I found feveral foft tubercles fituated at 
the verg-e of the anus. Thofe which were the 

o 

moft prominent were fituated on one fide of 
the anus; on the oppofite fide there were; 
none very prominent, 

I recom-t 



Procidentia Ani. 429 

I recommended the operation which I had 
performed in Mr. W/s cafe, and with the 
confent of my patient I extirpated the larger 
tubercles on one fide of the anus. 

The part was healed at the end of three 
weeks, and Mr. K. returned home much 
relieved. He favoured me with an account 
of his ftate in June 1791? and again in Sep- 
tember 179-2. In thefe letters he informed 
me, that the operation had answered his 
expectation, io that he could ride or walk 
without the leaft inconvenience. However, 
the fmall tubercles which were left had rather 
increafed in fize, and fometimes difcharged 
blood. The part on which the operation had 
been performed remained fmooth, but was 
not free from occafional difchar^es of blood. 

He continued to have a flight degree of 
prolapfus upon going to ftool ; but even when 
the feces were hard the gut afcended fpeedily, 
and without afliftance. 

He concludes his laft letter by faying, " I 
am well fatisfied with the operation/' 

CASE III. 

January 28th, 1791, Mr. E. of T. con- 
futed me on account of a diforder which he 

called 



430 Procidentia Ani. 

called the bleeding piles, and gave me the 
following relation of his cafe. 

For three. or four years'- he had been fub- 
ject to bleed at the anus upon going to ftool; 
at which time he felt an unufual preffin^ 
downwards. But it was not till within the 
laft five or fix months that he was confcious 
of any defcent of the gut: during which 
time it had defcended always when he went 
to the vault, and he feldom failed on that 
occafion to bleed conliderably. The blood 
flowed from him in a ftream; and the hae- 
morrhage had mcreafed to fuch a degree, 
that according to his own eftiniate, he had 
of late loft near a pint of blood at a time. 
Of this, however, he could not be certain; 
as he never made ufe of a clofe ftool. He 
could generally reduce the prolapfed part by 
gentle long continued preffure; but fome- 
times it remained down for twenty-four hoursj 
during which time he had a copious difcharge 
of bloody ferum. / 

He dually had i a. ftool every fecond or 
third day. 

Thefe frequent and large bleedings had 
reduced him, and made him weak ; yet his 
pulfe was not frequent, nor very feeble. He 
had confulted, a phyftciaix a.nd furgeon m 

the 



Procidentia Ani. 431 

the neighbourhood ; but, as the latter informed 
me, no examination had been made of the 
parts affecled. When I vifited him this day 
at T. I examined the ftate of the anus* and 
found no protrufion of the interior parts; 
but there was a pendulous flap of inte- 
guments, about three-fourths of an inch in 
length, which in part furrounded the anus. 
As he had no ftool while I . remained at his 
houfe, though I ftaid all night there, I could 
form no judgment of the prolapfus but from 
his own account. 

I advifed him to mjecl every other day a 
mild clyfter, made with a pint of water-gruel 
and a large fpoonful of treacle ; and to take 
in the morning, a few hours before the in- 
jection of the clyfter, a defert fpoonful of 
caftor oil, I cautioned him againft fitting 
long at the vault, or ufing any ftraining 
efforts. I informed him that the prolapfed 
inteftine would produce a fenfation as if he 
had not difcharged all the feces; and begged 
that he would be particularly aware of this 
deception, left he mould increafe the haemor-* 
rhage by unneceffary ftrainings. I advifed 
him to warn the prolapfed part with the 
aftringent lotion which I had recommended 
to Mr, W, (Cafe I.); and, until that could 

be 



432 Procidentia Ani. 

be prepared, to make ufe of brandy m the- 
fame way. And I Recommended to him to 
reduce the inteftine immediately after the 
warning, which was to be ufed as fc-on as 
the feces were difcharged ; that, if the ha> 
morrhage mould return, it might be fup* 
preffed as foon as poffible. 

This method of treatment prevented the 
return of the hemorrhage, but did not cure 
the prolapfus. Mr. E. afterwards informed 
me, that he thought he had greater diffi* 
fculty in reducing the prolapfed inteftine after 
he had ufed the aftringent lotion for a week 



or two. 



Finding the complaint at a ftand, he came 
to Leeds on March 1 4th, that he might be 
more immediately under my care. He then 
complained of conftant uneafmefs at the 
anus : and, upon examination, I found en* 
gaged within the fphin6ler ani a fmall por* 
tion of inteftine, the extremity of which was 
vifible externally, and had a livid hue. I 
was of opinion, from the account which he 
gave me, that this part had remained pro- 
lapfed during the laft fix or feven days. I 
informed him of his fituation* and advifed 
him to reduce the part immediately* His 
bowels were kept open; and he was enjoined 
2 to 



Procidentia Ani. 433 

to abfiain from exercife until this part fhould 
have regained its natural ftate. 

At the expiration of a week I carefully 
examined the affected parts, after he had 
walked awhile abroad, and found a fmall 
portion of the inteftine adhering in one part 
to the fphinfter ani. This adhering portion 
I extirpated with a pair of fciffars; hoping 
that the removal of it might allow the re£lum 
to retire into its natural pofition, and perhaps 
might prevent the procidentia. At any rate 
I thought it right to ufe firft a method more 
gentle than one which I had in view, and 
which I referved to the time of neceffity. 

This treatment afforded no relief; but the 
inteftine defcended as ufual when the patient 
went to ftool. I now determined upon ufing 
the method which had fucceeded fo well in 
the two preceding cafes. 

Friday, April 8th, after having informed 
my patient of the nature and necefiity of the 
operation which I propofed for his relief, and 
encouraged him with the hope of a favoura- 
ble termination; I removed the pendulous 
flap clofe to the anus, and cut off about 
a quarter of an inch of the interior red lining 
of the fphinfter ani, formed by the extremity 
of the inteftine, which was rather loofe, and 

F f projected. 



434 Procidentia Ani. 

proje&ed a little. A fma'll artery was opened 
on the left fide, which bled freely for a fhort 
time; but, as the extremity of it lay loofe 
without any immediate connexion with the 
cellular membrane, and as it foon ceafed to 
bleed, I did not apply a ligature. 

About an hour after the operation, I was 
fent for in hafte, and found the wounded 
parts bleeding freely. I was obliged to take 
up, with a needle, a blood- veffel on each fide 
of the anus. The application of the ligature 
was attended with considerable difficulty, and 
could not be effected until an affiftant had 
feparated the wounded parts as much as pof- 
fible. 

Sunday 10th, Mr. E. took a table-fpoon- 
ful of ol. ricini, and had a-ftool, without either 
hemorrhage or defcent of the inteftine. 

Tuefday 12th, he took another dofe of 
the oil, and had three ftools in the courfe of 
the day. At the third ftool, which was at- 
tended with unufual irritation, the prociden- 
tia ani returned. I was not informed of this 
event 'till Wednefday morning, when 1 ef- 
fected the reduction of the inteftine without 
difficulty. 

Wednefdav noon I found the out In it's 
prolapfed ftate agaiiij and was informed, 

that 



Procidentia Ani. 435 

that it Irad come down almoft immediately 
after I had left my patient in the morning. 
Mr. E. had alfo reduced it, but without any 
permanent good effect. The parts were now 
very fore, and the inteftine had begun to 
change colour. I gave him Tin6l. Opii g tts xx, 
to remove the uneafinefs, which was conftant; 
and advifed the application of a poultice of 
milk and bread, to abate the forenefs. 

I found him much eafier in the evening, 
but the gut was in the fame ftate. I thought 
it better to try the efTe6l of cold applications, 
than to repeat the handling of the parts ; and 
defired him to keep cloths dipped in cold 
water conftantly applied, and to change them 
frequently. 

Thurfday 14th. He had had much head- 
ach in the night, and had been reftlefs; yet 
his pulfe remained calm, and he had very 
-little uneafinefs. The gut was in the fame 
ftate. He had ufed the cold wet cloths in 
the evening for two hours, but without the 
defired effe<5t. I again replaced the prolapfed 
part of the inteftine, which was about the 
fize of a large nutmeg; and held the part in 
its natural fituation for a minute or two. 

In the afternoon I repeated my vifit, and 
had the fatisfaclion to find that the natural 

f F 2 contractile 



436 Procidentia Ani. 

contractile power of the inteftine had effected 
what I had attempted in vain. The gut had 
defcended foon after I left him in the morn- 
ing, as my patient thought, but had after- 
wards retired fpontaneouily, after having 
been down, in general, for forty-eight hours. 
After this time the procidentia ani returned 
no more ; but the cure proceeded as well as I 
could wifh. I directed a laxative clyfter every 
other day, to procure an eafy motion; but 
did not permit Mr. E. to take the caftor 
oil, or any other purgative, until the parts 
were healed. He was perfectly well at the 
expiration of three weeks after the laft ope- 
ration. 

CAS E IV. 

William Willans, of Hunflet, weaver, aged 
thirty-three years, was admitted a patient of 
the General Infirmary at Leeds, under the 
care of Dr. Davifon, 

As he complained of a frequent procidentia 
ani^ I was defired to examine the part. I 
found a tumour about the fize of a large 
nutmeg, confifting of a portion of the rectum 
inverted, which had defcended on the right 
fide of the anus, and adhered to the inte- 
guments^ 



PliOCIDENTIA Axi. 437 

guments, which immediately furround the 
anus, on that fide. The integuments made 
a pendulous flap when the inteftine was pro- 
lapfed; but when it was reduced, that flap 
was drawn inwards, and the anus had its 
natural appearance. A portion of the villous 
coat of the rectum, about the breadth of a 
filver three-pence, was abraded. The patient 
gave me the following hiftory of his com- 
plaint. 

About thirteen years ago he began to be 
afflifted with the bleeding piles, having fome 
pain and haemorrhage when he went to ftool. 
He had rarely an evacuation without a dis- 
charge of blood, which Sometimes flowed 
from him in a ftream. He was not then 
fenfible of any defcent of the inteftine; but 
about ten or eleven years ago a portion of 
the gut began to defcend at every evacuation. 
This defcent w r as not, however, confined to 
the times of his going to the vault; it came 
on alfo while he was employed in labour. 
The complaint gradually increafed; but was 
not always equally troublefome. Sometimes 
he was free from the prolapfus for a week or 
two, except when he had a ftool : at other 
times the gut would defcend repeatedly in 
the fpace of an hour, while he was fitting 

p F 3 employed 



438 Procidentia Ani. 

employed in his occupation of a carpet weaver. 
Now and then the part became fo fore with 
the frequent reduction, that he was under 
the neceffity of fuffering it to remain pro- 
lapfed until reft in a horizontal pofture had 
fo far abated the forenefs, that he could bear 
the pain of attempting its reduction. 

Since he came into the Infirmary he had 
been unable to pump water into a cittern, 
without bringing on the procidentia ani. 

This diforder had reduced his ftrength con- 
fiderably, fo that he was almoft rendered 
unfit for the profecution of his ufual employ- 
ment. 

September 10th, I requefted a confuta- 
tion of the other furgeons who attend the 
Infirmary; and after informing them of the 
fuccefs which I had met with in the cure of 
this obftinate difeafe, by the method related 
in the preceding cafes, I propofed making 
ufe of the fame for the relief of this patient. 
Mr. Lucas recommended the feparation of 
the inteftine from the flap of integuments, 
without the exciiion of any part, as a method 
likely to give lefs pain to the patient, and to 
prove equally fuccefsful. In compliance with 
his advice, I made fuch a feparation, and 
then reduced the inteftine. 

This 



Procidentia Ani. 439 

This operation proved rather more tedious 
than that of excifion. The inteftine defcended 
about two hours after the operation, although 
the patient had remained in bed in a hori- 
zontal pofition. 

Whenever he had a ftool, whether fponta- 
neoufly, or by the affiftance of laxative medi- 
cines given internally, or by clyfter, the 
evacuation was attended, except on one day, 
with a defcent of the inteftine. 

The wounded parts were healed in the 
fpace of three weeks. The gut continued 
to come down whenever he had a ftool; but 
he could reduce it with more eafe ; and when 
he left the Infirmary he had no prolapfus 
except at the time of going to ftool. He did 
not choofe to fubmit to any farther operation 
in order to obtain a more perfect cure. 

In the beginning of January 1 792, he 
called upon me to inform me, that the in- 
teftine had beg^n to defcend a little now and ia*/ 
then, when he did not go to ftool. I advifed / 
him to ufe the aftringent waft), made with 
infufion of oak bark in lime water, &c. as 
mentioned above. 



TV 4 



440 Procidentia A^j, 

case v. 

The following cafe is fo well defcribed by 
the lady who was the fubje6i of it, and who 
wrote it down at my requeft after her reco-? 
very, that I have nothing to add but an 
account of the means ufed for her cure. 

" Dear Sir, 

" If I could have the moft diflant 
hope, that a ftatement of my cafe would 
be of ufe to any of my fellow creatures, it 
would be a great gratification. The con- 
u . fideration that it is poffible you may have 
44 a fimilar cafe, is a great inducement to me 
" to make an attempt to defcribe my truly 
" diftreffing lituation, though I am fenfible 
I am very unequal to the undertaking. 

It is more than twenty years fince my 
complaint firft made its appearance. At 
firft a fmall part of the feat came down 
* when I had an evacuation, but when re- 
" turned gave me little pain or inconvenience. 
It continued in this ftate fome years. Af~ 
£i terwards the part became more relaxed, 
and frequently came down when I walked, 
or flood, particularly in warm weather. 
" After I had continued in this fituation 
*** " fome 



« * 



6i 



v.: 



Procidentia Ani. 441 

" fome time, the part became very fore, and 
** came down in a much greater degree, and I 
" had very frequent bleedings, and during the 
w difcharges I was generally reduced very 
" low and weak. Sometimes I have been a 
" month or fix weeks without any returns of 
" the bleeding, 

" In 06lober laft the forenefs and bleedine 
■" came on in fo terrible a manner, I was 
•" reduced to the greateft diftrefs and weak- 
? nefs. I daily loft fix or eight ounces of 
" blood when I had an evacuation, and the 
c< pain would continue many hours fo violent, 
" I was under the neceffity to prefs upon 
*' the part, which was the only relief I had. 

" In January (1799) I came to Leeds. 
W It is unneceflary to fay what was done 
# there." 

The lady was at this time much reduced 
by the frequent and copious haemorrhages 
from the re<5tum. I found, upon examina- 
tion, a foft tubercle on two oppofite fides of 
the anus, which did not retire along with the 
prolapfed parts of the rectum. Thefe I extir- 
pated, but at different times, wifhing to try 
whether the removal of one of them might 
not bring on a fufficient ftriclure, upon heal- 
ing, to fupport the extremity of the reftum. 

The 



442 Procidentia Ani. 

The good effects produced by thefe operations 
are defcribed in the fubfequent part of her 
letter, in the tranfcript of which I {hall or^it 
one fentence, as it only contains the effufion 
of kind partiality. 

" I am now by the bleffmg of God, and 
the means ufed, wonderfully reftored. I 
can now walk as far as my ftrength will 
allow, without any inconvenience from my 
old complaint, though it yet comes down 
in a fmall degree when I have an evacua- 
tion, but never at any other time. I have 
had no return of the bleeding, or forenefs, 
and at prefent I am very comfortable, and 
I have every reafon to hope I {hall conti- 
nue fo. - 

48 I did not think I was within the reacli 
of human aid. I have only to regret that 
I did not apply fooner, as my conftitution 
would not have received fo fevere a mock, 
as I am fenfible it has done from the long 
continuance of my complaint. I am yet 
weak and low, and I have not the perfect 
ufe of my legs ; but I am happy to fay I 
recover daily, and I truft I am again to 
know the bleffino; of health. 

" I am, &c. 
* June 26th, 1799. « J. T." 



[ 443 ] 



Tumour in the Rectum. 

CASE VI. 

In O&ober 1764, I was confulted by 
William Hargrave, of Bramley, near Leeds, 
on account of his fon, about eighteen years 
of age, who had had for two years a tumour 
in the re&um, which was protruded without 
the anus, whenever he had a ftool, and gene- 
rally difcharged blood at thofe times. This 
complaint had been attended from its begin- 
ning with pain in the lumbar region, which 
commenced upon his receiving a blow on 
that part as he was ftooping. He had never 
been healthy fmce this accident. His appe- 
tite was great, but he was foon faint after 
eating. He was extenuated, and had loft 
much of his flrength. 

I defired the young man to fit down upon 
a clofe-ftool, containing a little warm water, 
and to ufe fuch efforts as he knew would bring 
the tumour into view. I found it to be 
about the fize of a nutmeg, adhering to the 
inteftine by a narrow bafis. In its appear- 
ance it refembled a large pile; but was of 

a firmer 



444 Tumour in the Rectum. 

a firmer texture than the piles ufually are, 
unlefs when inflamed. 

I recommended the extirpation of this 
tumour; but did not think excifion to be 
advifable, as it would have been very diffi- 
cult to reftrain a haemorrhage in a part of 
the inteftine fo diftant from the anus, as 
that occupied by the bafis of this tumour, 
I therefore made a ligature round the bafis, 
and then puihed up the tumour into its 
place above the fphincter ani. On the third 
day I found the tumour much fhrivelled, and 
applied a fecond ligature. Neither of thefe 
operations gave my patient any confiderablo 
pain. 

On the 5 th, the father of the young man 
informed me, that the ligatures had come 
away without his fon's knowledge, who was 
now quite eafy. 

The haemorrhage returned no more after 
the extirpation of the tumour, and the young 
man foon regained his perfect health. 



[ 445 ] 

C H A P. XII. 
Of the Cancer of the Penis, 



CASE I. 



William Bromitt was admitted into 
the General Infirmary at Leeds in 1774, for 
a cancer of the penis. He had from his in- 
fancy been fubject to a natural phymojis, fo 
that he had never been able to draw back 
the prepuce. The difeafe began by a pain- 
ful fwelling of the extremity of the penis; 
on which account the prepuce had been di- 
vided in three places by a Frenchman, who 
then praclifed furgery at Y* 7 akefield.* 

From the time that thefe incifions were 
made, a large irregular fungus had fprouted 
out from the extremity of the penis, which 
continued fpreading, till it had occupied all 
that part of the penis which naturally pro- 
jects beyond the fcrotum. Neither the pre- 
puce nor the glans penis could now be dif- 

* This account 1 received from the patient, who, 
not being able to denude the glans penis, might not 
know whether the difeafe originated in the prepuce 
or in the glans. 

tin6lly 



446 Cancer op the Penis. 

tinctly perceived; but the whole projecting 
part of the penis formed a confufed mafs x)f 
irregularly granulated fleih, -which difcharged 
a very fetid matter* That part of the penis 
which was. covered by the fcrotum and pe- 
rineum appeared to be found, being free 
from any morbid hardnefs. I extirpated the 
penis clofe to the upper part of the fcrotum. 
One artery on the dorfum penis, and one in 
each corpus cavernofum, bled freely; fo that 
I was obliged to apply a ligature to each 
veflel. 

I apprehended that it might be of fervice 
to my patient, in this cafe, if the extremity 
of the urethra was fuffered to contract itfelf ; 
as the urine would then be projected to a 
greater diftance^ and would not be fo apt 
to run down the fcrotum. I therefore omit- 
ted the introduction of a bougie, till. he began 
to complain that he could not make water 
without feme difficulty. I now found that 
I had too lori£ deferred the introduction of 
a bougie, as the urethra would fcarcely ad- 
mit a very fmall one. I directed that a 
fmall bougie, about an inch in length, mould 
be retained in the urethra. But, about 
twelve hours after its introduction, the pa- 
tient was feized with a Slivering, fucceeded 

b J 



Cancer of the Penis. 447 

hy feverifhnefs. The bougie was then with- 
drawn, and a cooling laxative was adminiftered. 
The complaint went off in a few days, though 
not without a fmall difcharge of purulent 
matter from the urethra. He made water 
with lefs difficulty afterwards. 

He was difcharged, cured, a month after 
the operation. The urine flowed in a fmall 
ftream when he made water; but it was 
projected to a confiderable diftance from the 
penis, when he drew up the integuments 
covering the pubes. 

About a month after his difcharge from 
the Infirmary he applied to me, requefting 
that I would introduce the bougie, as the 
urethra had ao-ain become more contracted. 
The introduction did not give him pain, but 
brought on a feveriihnefs, as it had done before. 

I advifed him to continue the occafional 
introduction of a fhort bougie. 

I faw this patient fome years afterwards; 
and he had then fuffered no return of the 
cancerous complaint. 

C A S E II. 

In the fpring 1 779, Mr. M. of N. W. 
confulted me on account of a cancerous ex- 
crefcence, which occupied the whole of the 
glaas penis, and a part of the corpora caver- 

nofa. 



448 Cancer or the Penis. 
nofa. The diforder had appeared about & 
year before, and had commenced by a dif* 
charge of purulent matter, from the extre- 
mity of the prepuce. He had a natural phy- 
mo/is, fo that the ftate of the glans penis at 
that time could not be feen. His complaint 
was treated as venereal by the furgeon whom 
he firft confulted. Finding no relief, after 
a trial of fome months, he confulted another 
furgeon, who divided the prepuce, and at- 
tempted to bring on a falivation. A confi- 
derable degree of inflammation was the con- 
fequence of this treatment; and a third fur- 
geon was confulted: who, after removing 
the inflammation by emollient applications, 
tried to bring on a healing of the fore by 
digeftives and gentle efcharotics. The com- 
plaint being rendered rather worfe by thefe 
applications, he defifted; and treated the 
diforder as cancerous, by applying the cicuta 
externally, and giving it internally in large 
dofes joined with the bark. The patient re-r 
ceived no benefit from thefe remedies. He 
had been much reduced, as he informed me, 
during the treatment with mercurials ; but 
had regained his flefhwhen he came to Leeds, 
and had a good countenance. 

There was a part of the penis between the 

cancerous 



Caistcer of the Penis. 449 

Cancerous excrefcence and the pubes, which 
appeared to be in a found ftate. The reft 
of the corpus cavernofum and urethra wa$ 
alfo free from induration. 

So far the cafe feemed proper for amputa- 
tion. But there was a hard tumour, about 
the fize of a horfe-bean, in the integuments 
covering the ofla pubis* which made me fear 
a return of the complaint. However, as there 
was not the leaft hope of a recovery by any 
other means> and as the fmall tumour ad- 
mitted of extirpation, at the requeft of my 
patient I performed the operation, and ex-» 
tirpated this tumour, as w r ell as the difeafed 
part of the penis. 

I rolled a piece of tape round the found 
part of the penis ; which enabled me to ex- 
tirpate with more precifion juft fo much of 
the integuments, and body of the penis, as 
I wifhed to remove. I cut off, not only the 
excrefcence, but alfo all that part of the 
penis which was covered with difcoloured in- 
teguments. The haemorrhage was confider* 
able ; the blood not only flowing from many 
confpicuous arteries, but oozing largely from 
the divided corpora cavernofa. I took up 
one artery in the dorfum penis, and one in 
each corpus cavernofum. The bleeding, which 

G g ftill 



450 Cancer or the Pe^is. 

ftih continued, feemed then to be a general 
oozing from the wound: on which account 
I applied the.fpun.ge in the manner recom- 
mended by Mr. White. 

Aboutan hour after Mr. M. had been put 
to bed, , the bleeding became confiderable 
again; and I was obliged to remove the 
drefiings, and to take up three other arteries. 
A fourth yeffel, which feemed to run in the 
feptum of the corpora cavernofa clofe to the 
urethra, bled a little; but,' as I could not 
difcover clearly its extremity, I contented 
my felf with applying a piece of fpunge to 
the part whence the blood iffued. 

On the third day after the operation, ^ 
frefti haemorrhage came on, which compelled 
me to remove the piece of fpunge that I had 
applied, and which now adhered clofely to 
the wound. 

The haemorrhage arofe from that artery in 
the feptum which I had before feen indif- 
tinfitly, but which now bled freely. 

The cure proceeded very well; except that 
the wound in the pubes, made by the extir- 
pation of the fmall hard tumour above men- 
tioned, remained in a foul ftate. The appli- 
cation of the jmlvk angelicus brought the 

fore 



Cancer of the Penis, 451 

fore into a clean ftate ; and it afterwards 
healed. 

I made ufe of a bougie occasionally, though 
the extremity of the divided urethra did not 
contract fo much as in Bromitt's cafe. 

Though the excifion was made at fuch a 
diftance from the pubes, as to permit me to 
apply a piece of tape three quarters of an 
inch in breadth round the found part of the 
penis; yet immediately after the operation 
the penis became retracted within the fcro- 
tum ; and a hollow, inftead of a projection, 
remained after the cicatrization of the wound. 

Mr. M. was under the neceffity of ufing 
bougies occaiionally after his return home; 
but I never heard that he had any return of 
the cancerous diforder. 

CASE III. 

In July 1781, T. M. Efq; of A. confulted 
me on account of an excrefcence within the 
prepuce, which he had difcovered a few 
months before. It was hard, and had an 
uneven furface. It was attached both to the 
prepuce and glans penis. I could fee a part 
of it, though he could not denude the glans, 
having had from his infancy a natural phy- 

G q % mojis, 



452 Cancer of the Penis. 

mojis. A large quantity of fetid ichor was 
difcharged from the difeafed part. 

I could not doubt that the complaint was 
of a cancerous nature, and therefore I ad- 
vifed extirpation as the only method. of cure 
which was likely to prove effectual. 

This gentleman was in the iixty-third year 
of his age, and feemed to have a good con- 
ftitution. He was fubje6t to difcharge final! 
fand in his urine ; and had fometimes flight 
attacks of the gout. 

I performed the operation in Auguft. The 
arteries which ran in the centre of the cor- 
pora cavernofa penis gave me no trouble. 
But I was obliged to take up four which ran 
upon the dorfum penis. 

I made an attempt to heal the wound by 
the firft intention; and, for that purpofe, I 
brought the integuments over the divided 
corpora cavernofa, fecuring them, as well as 
I could, with court plafter. That I might 
make the integuments lie upon the wounded' 
extremity of the penis without puckering, 
I made a longitudinal division of them at the, 
inferior part of the penis; by which method 
I could cover the corpora cavernofa without 
covering the urethra. I introduced a finall 
filver canula into the urethra; that the in- 
2 teguments 



Cancer of the Penis. 453 

teguments might not Hide over ihe extremity 
of that canai, and that the leaft pofiible clif- 
turbance might be given to the parts in his 
efforts to make water. 

Whenever my patient made any exertion, 
the blood gullied oat from the corpora caver- 
nofa; but there was no bleeding while he 
lay ftill in bed. I directed an aililtant to 
place his fingers upon the extremity of the 
corpora cavernofa whenever Mr. M. had 
occafion to make water, or to ufe any other 
exertion. This attention was necefiary dur- 
ing two or three days after the operation; at 
the end of which time the oozing of blood 
ceafed. 

I was difappointed in my delign of healing 
by the firft intention; for the integuments 
would not adhere to the extremity of the 
corpora cavernofa. Thefe fpungy bodies, 
when divided, do not readily throw out gra- 
nulations ; but have ufually for feme time an 
ill-conditioned appearance. 

I removed the canula, and dreffed the 
wounded parts with digeftive; covering the 
whole with a foft pledget of cerate, and in- 
troducing a fhort bougie daily, as the urethra 
mewed a great tendency to contract itfelf. 

G g 3 The 



45.4 Cancer of the- Pettis. 

The wound was cicatrized at the expira-* 
tion of five weeks; and the remaining part 
of the penis did not retire within the* 
fcratum. 

This gentlemen had never any leturn of 
the fame difeafe in the penis, nar elfewhere. 
He died fome years afterwards from a ftone 
in the bladder, and general debility. 

Upon examination after death, I found the 
ftone formed fomewhat like an hour-glafs, 
and retained in one pofition by the com- 
traclion of the bladder upon the; middle part 
of it, 

CASE IV. 

' Auftin Wray, a middle-aged labouring man ? 
was admitted a patient of the General Infir- 
mary at Leeds in 1782, for a cancer of the 
penis. He had had the difeafe about a year 
and a half before his admiffion. The parts w r ere 
in a ftate of great inflammation, from the 
application of fome efcharotics, which had 
been ufed by an ignorant quack whom he 
had lately confulted. The glands in the 
right groin were likewife much tumefied. 

Emollient poultices and cooling medicines 
were adminiftered, to take off the inflam- 
mation* 



Cancer of the Penis. 455 

mation. Thefe means produced their intended 
effeft; but the induration of the inguinal 
glands remained. 

A confutation of the furgeons of the In- 
firmary was held upon the cafe of this poor 
man. As we had no hope of curing this 
ulcerated cancer by any remedies yet known; 
as the penis, betwixt the excrefcences and 
the pubes,* appeared to be in a found itate; 
*and as the inguinal glands had not become 
enlarged until the application of the efcharo- 
tics; we judged it proper to propofe the am- 
putation of the difeafed part to our patient. 

I performed the operation September 5th, 
and was obliged to take up fix arteries be- 
tween the integuments and the corpora caver- 
nofa. The artery, which runs in the centre of 
each corpus cavernofum, did not require a 
ligature. 

I was obliged to make frequent ufe of a 
ihort and thick bougie during the cure. 
Whenever this was omitted the man found 
a difficulty in making water. The wound 
was cicatrized in the fpace of five weeks. 

I gave him the Extraftum Cicuta? for 
fome time after the wound was healed. The 
enlargement of the inguinal glands gradu- 

g g 4 ally 



,456 Cancer of the Penis* 
ally leaned for a time; but afterwards in- 
creafed confiderably. The man became 
weak and languiihing, and died from a re- 
turn of the complaint; though there was 
never any frefti ulceration, 

CASE V, 

In 1801, J. L. of Leeds, an elderly man 3 
confulted me on account of fome excrefcences 
on the extremity of the penis. They were 
evidently of a cancerous nature, and appeared 
to be confined to the prepuce, the greater 
part of which was in a morbid ftate. He 
did not remember ever to have been able 
to denude the glans penis, He readily fub^ 
mitted to the operation which I judged ne- 
ceffary to effe6t the cure of his diforder. 
My defign was to have removed thofe parts 
only of the prepuce which bad a morbid ap- 
pearance; but upon attempting this I found ? 
that a part of the prepuce adhered to the 
corona glandis, and had brought it into a ftate 
of ulceration. I thought it neceffaxy there-* 
fore to extirpate the extremity of the penis as 
well as the prepuce, the internal membrane of 
which was in a much more rigid ftate than is na* 

turals 



Cancer of the Penis. 457 

tural. I was obliged to take up feveral ar- 
teries. A bougie was frequently introduced 
into the urethra during the cicatrizatioa of 
the wound, 

CASE VI. 

Mr. H. of Tan field, near Mafliam, con- 
fulted me in July 1801, on account of fome 
painful ulcerated excrefcences at the extre- 
mity of the penis, and gave me the follow- 
ing relation of the origin and progrefs of 
his complaint. 

He had a natural phymojis, having never 
been able to denude the glans penis. About 
two years and a half before he confulted me, 
he began to find great difficulty in making 
water. At this time there was no appear- 
ance of difeafe in the penis; at leaft, none 
had been difcovered; but the dyfury was 
attributed to the gravel. 

After fome time, one of the medical gentle- 
men whom he confulted, found, upon exa- 
mining the penis, that the prepuce was in 
ft difeafed ftate, and made a divifion of it 
on one fide, which greatly relieved the dy- 
fury. Some excrefcences were now difco- 
vered, arifing from the interior furface of the 

prepuce, 



45,8 Cancer of the Penis, 

prepuce, and thefe had continued to increafe 
in fize and forenefs from the time of their 
difcoverv. 

Thefe excrefcences appeared to me to be 
of a cancerous nature. They were in a for- 
did ftate, and occupied the inferior and la- 
teral parts of the prepuce. The fuperior 
part of the prepuce appeared free from dif* 
eafe, the extent of which could not, how- 
ever, be clearly afcertained, as the glans 
penis could not yet be completely denuded. 
I divided the prepuce in a part which was 
found, and at fame diftance from the former 
divifion which was incomplete, that I might 
fee whether the glans remained in a found 
ftate. Upon drawing back the prepuce com- 
pletely, I could perceive no difeafe in the 
glans; but the fnenum was ulcerated. 

I extirpated all the difeafed part of the 
prepuce, leaving only that found part which 
remained between the two divifions. The 
fnenum was also removed. 

The wound put on a favourable afpeeT;, 
■and healed fpeedily, fo that it was nearly 
cicatrized at the expiration of a fortnight 
after the excifion. 

March 23d, 1802. This patient lately 

informed 



Cancer of the Penis. 459 

informed me, that he had continued perfectly 
well lince his return home. 

CASE VIL 

A young man, by trade a hhoemaker, con- 
fulted me on account of a great difficulty in 
making water, which was attended with fome 
pain at the extremity of the penis. 

Upon examination I found the prepuce fo 
much contra6ted, that it would fcarcelv fuf- 
fer the urine to flow out. When I intro- 
duced a probe within the prepuce for tkc 
purpofe of examining its ftate, I found it to 
have an unnatural rigidity. The phymojis- 
I apprehended to be congenital, as the patient 
did not remember to have been able at any 
time to denude the glans penis. I urged the 
neceflity of dividing the prepuce, and he con- 
fented to the operation. Upon making a 
complete divilion of the prepuce laterally, on 
each fide, I found its interior membrane much 
more firm and rigid than it is in its natural 
ftate, fo that it greatly resembled a piece of fine 
parchment. Minute tubercles appeared h*j're 
and there on its internal furface; but none 
of them feemed tending to ulceration. I did 
not remove any part of the prepuce; but 

left 



460 Cancer of The Penis. 

left it in fuch* a ftate that tne glans penis 
might be denuded with eafe. 

This operation was performed feveral years 
ago, and I have heard nothing of the patient 
dice his cure was completed, 

REMARKS. 

The preceding cafes of cancer in the penis 
afford a pretty good hiftory of the origin and 
progress of the difeafe, when affecting this 
part of the body. Six of thefe feven patients 
tad had a congenital phymoiis, which was 
certainly an extraordinary circumllance if it 
had no relation to the origin of the difeafe. 
The difeafe had made fucli progrefs in forne 
of the patients, as to deftroy entirely the 
natural appearance of the parts, before I had 
the opportunity of examining them: nor could 
I learn in thefe cafes, how the prepuce ap- 
peared before, or at the firft attack of the 
complaint. Where I had an opportunity of 
feeing the difeafe in an early ftage, the phy- 
mofis evidently appeared to have been caufed 
by a mal-conformation of the internal mem- 
brane of the prepuce; and the mal-conforma- 
tion feemed alfo to have given rise to the 
cancerous affection. 

Til 



Canceu of the Penis. A6\ 

In the 7th cafe we fee the difeafe in its 
firft ftage. The whole lining of the prepuce 
was in an unnatural ftate. But as this feemed 
to have been congenital, and as the tubercles 
were fo minute, that they appeared like mere 
inequalities in the thicknefs of the membrane, 
I did not think it neceffary to perform the 
operation of circumcilion. Whether the oper- 
ation which I performed put a flop to the 
progrefs of the difeafe I cannot tell. The 
young man was a journeyman fhoemaker, 
and lived in lodgings. I have lately tried to 
difcover his reiidence; but have not been 
able to gain any information refpecting him. 

The 6th cafe mews the difeafe fully formed, 
but not much advanced in its progrefs. The 
whole of the prepuce was not affetted, and 
the glans penis remained free from difeafe. 

In the 5 th cafe the diforder had made a 
little farther advance, and had begun to 
affecl the glans penis; but the morbid affec- 
tion had pretty evidently commenced in the 
prepuce, and had fpread from thence to the 
glans penis. 

I believe I mould not have performed the 
pperation in the 4th cafe, had not the fwel- 
ling of the inguinal glands been fo recent, 
and brought on, as we judged from the pa- 
tient's 



462 Cancer of the Penis. 

tient's account, rather by the injudicious ap- 
plication of efeharotics, than by a fimple 
extenfion of the difeafe* . 

The permanent cure effected in the three 
firft cafes ogf the operation^ mews that the 
amputation of the morbid part of the penis 
affords great hope of fuccefs in this fpecies 



of cancer. 



In amputating the penis, I found great 
advantage from having wrapped fome tape 
round the found part. 1 was hereby enabled 
to divide the integuments more eaiily, and cor- 
rectly ; and I was alfo furniihed with an ufeful 
kind of tourniquet, which fecured the divided 
veffels from bleeding, till I was prepared to 
take them up withthe tenaculum and ligature. 
It requires great care in this operation to 
fecure the larger arteries, as they are a]5t 
to lhrink, and conceal themfelves under the 
loofe integuments, to which thev have no 
ftrong attachment. 



[ 463 ] 



CHAP. XIIL 
Convulsions after Strangulation, 



May 1 8 lb, 1 782. In the evening Mr. * 

being greatly diftreffed on account of fome 
difagreeable circunrftances in bufinefs, rafhly- 
hanged himfelf. He was discovered by his 
fon foon after the commencement of his fuf- 
penfion, and on being cut down mewed fome 
figns of life. 

A furgeon, who lived near him, was imme- 
diately fent for; who, finding him lying infen- 
fible, and frothing at the mouth, and not 
being informed of the caufe of thefe fymp- 
toms, took about a pound of blood from the 

arm. Soon after the evacuation Mr. 

was feized with convulsions. A bliftering 
plafter was then applied betwixt the moulders; 
and fome fpirit of hartmorn was fent, with 
directions to give a little in water whenever 
it could be got down. When the convul- 
fions had continued, an hour without inter- 

miffion, 



464 Convulsions afteh 

million, I was defired to vifit the patient, 
having attended the family in ordinary for 
ibme years. 

I found him lying on a bed, which was 
placed on the chamber floor near an open 
window. He was infenfible* and violently 
convulfed. His hands and feet were cold; 
the reft of his body was hot, and in a pro- 
fufe perfpiration. He was held down by 
five or fix ftout men, to prevent any injury 
to himfelf from the violent and almoit incef* 
fant agitations which he fuflfered. 

I was of opinion that thefe convulfions 
were the effect of debility, brought on by the 
fufpenfion, and probably increafed by the 
copious evacuation of blood. 1 determined 
therefore to give him fome ftimulating medi- 
cines as foon as he could fwallow them; and 
that I might be ready to feize the firft op- 
port unity, I fent for fome iEther, Spt. Am- 
monia?, and volatile Tinfture of Valerian. 

I requefted a confutation, and the late. 
Dr. Hird was defired to attend. In the mean 
time I directed the patient to be placed in 
w r arm blankets upon his own bed, and wrap- 1 
ped his feet in hot flannel. Just before his 
removal I made an attempt to give him fom© 
warm wine, and fucceeded in getting down 

a few 



Strangulation. 465 

a few ounces, by putting a large fpoon be- 
twixt his teeth during a fliort interval of 
quiet, and pouring the wine into the fpoon 
while his teeth were kept afunder by it. As 
foon as the wine was fwallowed he belched, 
and feemed to be fomewhat relieved. 

When Dr. Hird arrived, I informed him 
of what I had done. He concurred with me 
in the mode of treatment which I had adopt- 
ed, and we determined to give our patient 
the volatile Tin6lure of Valerian in warm 
wine, as fpeedily as poffible. 

The affiftants having placed him in a fitting 
pofture in bed, I poured into his mouth, at 
two or three trials, about two drachms of the 
tincture, diluted with wine. No fooner had 
he fwallowed this mixture than the convul- 
sions ceafed inftantaneoufly. He was laid 
down in bed, and we gave directions that a 
tea-fpoonful of the tin6ture mould be given 
now and then, or as foon as ever the convul- 
fions mould return. 

I was called to vifit him again betwixt one 
and two o'clock in the night, and was in- 
formed, that he had lain quiet during two 
hours after Dr. Hird and I had left him at 
nine in the evening. The convulfions then 
returning, the Tin&ure of Valerian was given, 

H H and 



466 Convulsions after 

and the fame pleafing effect was produced, 
viz. an immediate ceffation of the agitations. 
The convuliions, however, * returned twice ; 
and the laft interval of eafe having been but 
a quarter of an hour, I was requefted to 
direfit what might farther be done for his 
relief. 



r% , , „ was now m f tranquil a ftate, 
though infenfible, that the ufe of the warm 
bath (which I had mentioned before) was no 
longer impracticable. He was placed in a 
femicupium as foon as it could be got ready, 
and a large -bliftering plafter was applied to 
-his head* Sinapifms werealfo put to his feet- 
1 9th. At nine in the morning we found 
him better. He had had no convuliions 
fince the ufe of the warm femicupium. He 
had fpoken a few words fenfibly, and began 
to complain of the blifters. He difcharged 
part of his urine involuntarily.. His pulfe 
was at ninety-fix, with a moderate degree of 
ftrength. As he had had no proper evacu- 
ation fince the injury, the following bolus 
was ordered : 

W . Pulv. Rhei g r . xxv. 

Zinzib. g r . v. fy r . fimp, q. f. 

f. Bolus ftatim fumend. 

A faline 



STRANGULATlTtlNr. 467 

A faline julep was alfo prefcribed : thin broth, 
chocolate, and the like, were ordered for diet. 

5. P. M. He had retched after taking 
the bolus, but had had a ftool. He was 
now fo fenfible that he could give a pro- 
per reply to queftions refpe&ing his feel- 
ings; but he had a ftaring and hollow coun- 
tenance. The mark of the cord had not yet 
difappeared. Though much recovered fince 
the morning as to his understanding, yet he 
was now in a more languid ftate. His fingers, 
from their extremity to the middle joint, 
were pale as if benumbed with cold ; and his 
pulfe was fo feeble that it could fcarcely be 
diftinguiihed. In this ftate it feemed abfo- 
lutely neceflary to do fomething to roufe 
the vis vitce. A cordial draught, containing 
Tincl. Valer. volat. 5 j, was ordered to be 
given every four hours ; and a little wine 
was directed to be given to him frequently. 

20th. The draughts had agreed very well. 
The pallid appearance of his fingers was gone; 
and his pulfe had coniiderably increafed in 
ftrength. His underftanding was become 
quite clear. The draughts were continued 
every fix hours. 

From this time he recovered very well, 
except on account of a gangrenous flough, 

h h 2 which 



468 Convulsions after 

which came noon the fide of each foot. The 
finapifnis had been fuffered to remain fo long 
upon his feet, until they had caufed a blifter 
to rife upon the fide of each foot. Upon 
his beginning to walk about in his chamber,, 
an inflammation came upon the bliftered 
parts, and was fucceeded by a fuperficial gan- 
grene. By keeping him in bed, applying 
mild cataplafms, and giving him the Cortex 
Peruvianus, the fores became clean. Flannel 
rollers were then ufed, with proper dreffmgs, 
and he was permitted to w r alk about. The 
fores healed {lowly ; but he regained his health* 

R E M A R K S, 

This cale clearly points out th& impropri- 
ety of large and indifcriminate bleeding after 
ftrangulation, while the powers of life remain 
almoft fufpended. The extraction of a fmall 
quantity of blood from the jugular vein, efpe- 
cially in a plethoric, habit, might do good, 
when accompanied with the internal ufe of 
volatile, and -other itimulating medicines. 

The great advantage . of thefe remedies wa& 
evident, both m the firft inftantaneous remo- 
val of the convullions, as foon as the medi- 
cine 



Strangulation. 469 

cine reached the ftomach of the patient; and 
in the removal of that alarming debility which 
came on upon omitting for a time to give 
the volatile tincture and wine, on the day 
after the accident. 

The fmapifnis ought not to have remained 
upon the feet fo long as to veficate the parts. 
Ulcers produced by bliftering the feet are 
often flow in healing, in perfons of a languid 
habit. 

This cafe throws fome light upon the pro- 
per mode of treatment after fuffocation, and 
concuffions of the brain. In both thefe in- 
ftances I think copious bleeding to be inju- 
rious, daring the diminilhed ftate of the vis 
vitce, which immediately fucceeds the injury. 
In concuffions of the brain I have feen great 
benefit arife from the warm femicupium, and 
bliftering the head, after topical bleeding. 



II n 3 



[ 470 ] 

CHAP XIV. 
F A TtJMOtJIl IN THE NeCK 



September 28th, 1785, the late Rev. 
Mr. Eyre and his lady brought their youngeft 
child, aged four months, from Barnborough, 
to confult me about a tumour which had ap- 
peared on the left fide of the v neck, juft 
above the clavicle. The maid firft perceived 
this tumour four days before, as fhe was 
warning the child's neck. The tumour was 
now about the fize of a pigeon's egg, though 
much fmaller when it was firft difcovered. 
It had a bluifh appearance, fomewhat like a 
vein; was quite foft, and free from pain. 
It gave no impediment to the motion of the 
head. It was moveable, but not detached 
from the fubjacent parts. It feemed to be 
the moft tenfe when the child cried. No- 
thing had happened to the child in any 
refpecl remarkable, except that about a fort- 
night before this tumour was perceived me 
had cried, or rather fc reamed out fuddenly 
and violently. Upon undreffing her imme- 
3 diately, 



Tumour in the Neck. 471 

diately, nothing was perceived that could 
have hurt her. It was fuppofed me had 
been frightened, as {he continued to moan 
for a few hours, and then returned to her 
ufual cheerfulnefs. 

From weighing all thefe circumftances I 
was inclined to confider the tumour as arifing 
from a varicofe diftention of the veins of the 
neck, perhaps of the external jugular vein, 
as the tumour was lituated upon the courfe 
of that. vein. I was inclined alfo to attribute 
the origin of this difeafe to the violent fit of 
crying above mentioned, as the veins of the 
neck are much diitended at fuch times, and 
might be rendered varicofe by the violence 
of the effort. 

As I had feen two inftances, not long be- 
fore, of foft tumours in the fame part of the 
neck, which I confidered as varicofe, one of 
which gradually fubfided, and the other re- 
mained without injury to the patient; I ad- 
vifed nothing for the prefent, but warning 
the part frequently with cold water. I hoped 
that a little time would fully elucidate the 
nature of the complaint. 

A week after this examination, I received 
a letter from Mr. Eyre, informing me, that 
the tumour had increafed rapidly in their 

h h 4 return 



472 Tumour in the Neck. 

return home, and was now fo large as to 
alarm them much. At the expiration of the 
fecond week they returned to Leeds with the 
child. 

The tumour had increafed to four times 
its former fize, and the integuments feemed 
very thin at its moft prominent part. It 
defcended a little below the clavicle, and 
rofe as high as the angle of the lower jaw. 

There was now reafon to believe that the 
fluid in the tumour was extravafated, I there- 
fore propofed to puncture the tumour with , 
a fniall couching needle, to afcertain the 
nature of the fluid contained in it. If blood 
fhould flow out, the difcharge might eaiily 
be reftrained, and we could afterwards a6t 
as circumftances might direct. I defired a 
confutation, both on account of the obfcu- 
rity of the cafe, and that I might have pro- 
per affrftance if it fhould be found needful 
to open the tumour more largely, for the 
purpofe of taking up any ruptured blood- 
veiTel. 

The late Mr. Billam was confulted, and Mr. 
Walker, then an apothecary, in St. James's- 
ftreet, London, being at my houfe, faw the 
child along with us. Mr. Billam concurring 
with me in opinion, I punctured the tumour 

with 



Tumour in the Neck. 473 

with a round couching needle. Dark-co- 
loured blood iflued out in a fmall ftream, till 
the cup had received about a quarter of an 
ounce; the blood then continued to ooze 
out for about two hours. The puncture was 
healed in the courfe of the day. 

The next day (Friday) I punctured the 
tumour again with a broad couching needle. 
A fmaller quantity of blood iflued out, which 
was not quite fo dark coloured. This coa- 
gulated foon, whereas the former had re- 
mained fluid. 

Saturday. We found the tumour not in- 
creafed in fize fince the operation yefterday; 
we therefore deferred making another punc- 
ture. 

Monday. The tumour had not increafed. 
I punctured with a lancet the middle part, 
which was fofter than the reft. A fmall 
quantity of blood was difcharged. The re- 
maining part of the tumour, which was now 
reduced to a fmall fize, was folid, yet fofc, 
as if formed by coagulated blood. 

We now entertained great hopes that this for- 
midable difeafe would give us no farther trou- 
ble; but that the remains of the tumour would 
gradually difappear, or at leaft remain in this 
diminifhed ftate. But our hopes were foon, 

for 



474 Tumour in tije Neck. 

for a time, difperfed by an increafe of the 
tumour, which took place within a fe y hours 
after the laft punfture. The tumour in the 
courfe of the day became larger than it had 
been after the fecond operation. It conti- 
nued to increafe during: the two following 
days, and then became ftationary. We waited 
about a week, and then made another punc- 
ture. The blood which now flowed out was 
quite florid, like arterial blood, and coagu- 
lated immediately. 

After this pun6ture the tumour had no 
farther increafe. On the contrary, it gra- 
dually leffened, and became more moveable. 
However, I made another punfilure with a 
couching needle ; but although I pulhed the 
point of the inftrument about a quarter of an 
inch into the tumour, a few drops only of 
blood were difcharged. 

Our little patient was now taken home; 
the fmall remains of the tumour were gra- 
dually abforbed, and every appearance of 
difeafe obliterated. 

REMARKS. 

The perufaj of this cafe will, I apprehend, 
leave no doubt in the mind of the intelligent 

reader, 



Tumour in the Neck. 475 

reader, that fome blood-veflel in the neck 
had been ruptured. As the interior part of 
the tumour was not infpected, the fituation 
and other circumftances of the rupture muft be 
matter of conjecture. It gave me great plea- 
fure to fee this alarming difeafe fubdued by 
fuch gentle means, as there was at one time 
great reafon to fear, that I mould have been 
under the neceffity of laying open the tu- 
mour, for the purpofe of difcovering and fe- 
curing the ruptured veffel or veffels. 

I would take this opportunity of ftrongljr 
recommending the method here ufed of ex- 
ploring the contents of tumours in doubtful 
cafes. I have ufed it upon feveral occafions 
with great iatisf action and advantage. There 
are few doubtful cafes in which any harip 
could be done by the puncture of a couching 
needle. The contents of the tumour may be 
generally afcertained by fuch a puncture, the 
pain of which is trifling, and the wound is 
icon healed. 



[ 476 ] 



CHAP. XVe 



Of the Empyema, 



September 3d, 1788, I was defired by 
the overfeers of the poor of the townfhip of 
Headingley, near Leeds, to viiit John Wil- 
kinfon and his wife, who were then ill in the 
Influenza, which prevailed at that time. The 
man had been ill ten days. I found him 
labouring under a fever, attended with cough, 
difficulty of breathing, and pain in the left 
fide of the thorax. He was bled once; had 
repeated biifters applied to the thorax; took 
nitre and antimonials, with a fmooth linftus 
to allay his cough. He was relieved repeat- 
edly by thefe means, efpecially by the ap- 
plication of the biifters; but repeatedly re- 
lapfed. At laft he became fo ill, that he 
breathed with the utmoft difficulty; and could 
not lie on the right iide without danger of 
immediate fuffocation. My eldeft fon, who 
was then my afiiftant in bufinefs, had chiefly 

vifited 



Of the Empyema. 477 

vifited the family; but now defired me to fee 
the poor man, judging him to be in the 
molt imminent danger. 

I found him on the 17th of September, 
and the 27th day from the commencement 
of his diforder, in the ftate I have juft now 
defcribed. His face, and efpecially the eye- 
lid, were a little fwollen on the left fide. 
The left fide of the thorax was larger than 
the right, and its integuments were edema- 
toie. Upon preffmg the intercoftal mufcles, 
they felt diftended; they yielded a little to 
a ftrong preffure, and rebounded again. The 
abdomen, efpecially at it's upper part, ap- 
peared to be fuller than in its natural ftate. 

From thefe fymptoms I was perfuaded, 
that the left fide of the thorax contained pus 
or water; and, after explaining the nature 
of the dileale to the man's wife, who was 
now perfefiUy recovered, and to his mother, 
I propofed the operation for the empyema. 

The next day I performed it; having placed 
him upon a table, covered with blankets, 
near a window. The pain which he had 
felt. in his fide had been the mod acute be- 
twixt the fifth and fixth ribs, and there I 
mi ! e an opening into the cavity of the tho- 
rax. My firft inciiion was about two jnches 

m 



478 Of the Empyema. 

in length. I cut through the ferratus 
magnus arid intercoftal mufcles clofe to the 
upper edge of the fixth rib, and made an 
opening into the cheft capable of admitting 
the tip of my finger. Purulent matter im- 
mediately guflied out to a cbnfiderable dis- 
tance, and the quantity evacuated meafured 
five ale-pints. The poor man was much re- 
lieved, yet he did not breathe well during 
the two firft days after the operation. His 
cough and difficulty of breathing then abated 
very faft; and his pulfe, which, before the 
operation, had beat one hundred and ten 
ftrokes in a minute, foon came down to nine- 
ty, and at the expiration of a week did not 
exceed eighty-four. A leaden canula was 
introduced into the wound on the fecond 
day after the operation, and was retained 
in its place by a flannel bandage. ... 

Much coagulated matter iffued out during 
the firft two or threi days, and then the 
matter became thinner. 

My patient continued in a favourable ftate 
until tne beginning of winter, and then his 
fymptoms became unfavourable. The matter 
difcharged was more copious, and was fetid; 
his cough was more troublefome, and his 
pulfe became much quicker. 

When 



Of the Empyema. 479 

When the cough began again to be trou- 
blefome, I prefcribed for him an electuary 
with fpermaceti and nitre; but, upon the 
difcharge becoming more copious, thin, and 
fetid, I ordered a decofiiion of the bark to 
be given to him. This was exchanged for 
a decoftion of myrrh, in the proportion of 
half an ounce to a pint of water. This me- 
dicine he took throughout the month of Ja- 
nuary, together with half a grain, or a grain, 
of folid opium every night at bed-time. I 
requefted the overfeers to allow him as much 
new milk as he chofe to take, and advifed him 
to make this, with bread and rice, the principal 
article of diet. Thefe means agreed very well 
with him, and feemed to be of great benefit 
to him. In February he ceafed taking me- 
dicines. As the weather became warmer 
his ftrength increafed, and by degrees he 
recovered his health perfectly. I did not 
permit him to leave off wearing the canula 
until the difcharge from the thorax had 
ceafed, and he had completely regained his 
ftrength. He wore it fifteen months. - 

REMARKS. 

When an inflammation of the membrane 
of the lungs, and of the pleura, produces a 

mutual 



480 Of the Empyema. 

mutual adhefion of thefe parts, and a collec- 
tion of matter forming a tumour on the 
thorax ; the indication for performing an oper- 
ation to difcharge the matter admits of no 
doubt. But when the cavity on one fide of 
the cheft is filled with any fluid, without a 
wound or circumfcribed tumour exterior to 
the ribs, more circumfpe6lion is required to 
determine the propriety of an operation. 

I have inferted this cafe as a guide to the 
young practitioner, and hope that, in this 
view, it may be of ufe. Dr. Cullen, in his 
Nofologia Methodica, does not mention the 
oedema of one half of the body as a fymptom 
of Empyema, or Hydrothorax* I think it of 
great confequence to retain a canula in the 
wound until all probability of a relapfe is 
removed. This precaution, I apprehend, will 
not hinder the patient from recovering his 
ftrength, even when the ufe of the inftrument 
is not abfolutely necefiary. 

A young man, aged fixteen years, received 
the whole charge of a fowling-piece into his 
fide, the muzzle of the gun being very near 
him when it was fired. The greater part of 
the charge lay under the latiffimus dorfi, 
whence I cut it out. A fmall part of the 
charge penetrated the lungs, obliquely, be- 
tween 



Or the Empyema* 481 

tween the fix th and feventh ribs. The ed es 
of both the ribs were broken. I covered 
part of the wound with the integuments, unit- 
ing them by future. The integuments, by 
this method, formed a proper fupport for a 
eanula; which was introduced obliquely be- 
twixt the fixth and feventh ribs. The pipe 
of the eanula made fuch an angle with its 
rim, that the fliape of * the inftrument corre- 
fponded exactly with that of the wound. 

As pellets of lead and fmall fragments of 
bone were difeharged, now and then, both 
through the trachea and the canuH, for a 
long time after the wound was made, I did 
not remove the eanula till the expiration of 
twelve months after the accident. The ea- 
nula, during the cure, was taken out every 
day and warned, that no acrid matter might, 
by means of it,, be detained in the thorax. 
This patient is now a healthy man; but 
violent exercife is apt to bring on a fpitting 
of blood. He coughed up feveral pellets 
foon after the eanula was removed ; and there 
is yet, at times, a flight oozing of ferous fluid 
from the cicatrix. 



II 



[ «* ] 



CHAP. XVI. 



Of an Enlargement op the - Mammi, 



■■i hi m i ■( !' j i 



MANY circumftances ihew, that the Uterus 
and Mamma fyrapathize with each other, not 
only in child-bearing women ; but various 
morbid affections of the breafts alfo indicate 
a kind of permanent fympathy. I have re- 
peatedly feen the mammae become enlarged, 
where there appeared to be no other caufe 
than a deficiency in the menflrual evacua- 
tion, The following cafe of an enlargement 
of the mammae, which feemed to arife from 
an obftruction of the nienitrua, is fo remark- 
able, that it may defer ve to be recorded. 

Mary Bradford, aged fourteen years, was 
admitted June 8th, 1787, a patient of the 
General Infirmary at Leeds, on account of 
a very great enlargement of both the mammae* 
From her infancy they had been fomewhat 
larger than the natural fize. She was of a 
delicate habit; but was not unhealthy before 

the 



Enlargement of the Mamma. 483 
the attack of this difeafe. She began to men- 
ftruate when the was twelve years and a half 
old; and being ignorant of this habit of her 
fex, and afhamed to mention her (ituation, 
fhe waihed that part of her linen which was 
flamed, and continued to wear it while wet. 
The evacuation ceafed fuddenly, and had 
not returned when (he became a patient of 
the General Infirmary, 

Many means were ufed to bring on a re- 
gular menftruation, from a fuppolition that 
the enlargement of the mammae was owing 
to this obftructton. The obftru£tion, how- 
ever, was not removed, and the breafts con- 
tinued to grow larger. 

Her fituation was now truly deplorable. 
The fize of the breafts was fo enormous, that 
ihe could not walk upright. The conftant 
bending forwards had brought on a perma- 
nent curvature in the fpine. The dragging 
fenfation, arifing from the weight of her 
breafts, was fo troublefome, that Ihe was 
never eafy unlefs when lying in bed, or fit- 
ting with the breafts refting upon her knees. 
There feemed to be no method <*f relief re- 
maining but that of amputation. Upon a 
confutation it was determined to remove the 

I I 2 left 



484 Enlargement OF TTHE MaMmM* 

left breaft, which was the larger, and to wait 
the event of this operation. 

There appeared to be no difeafe in the 
breafts except that of fimple enlargement }■ 
and their weight had feparated them fo far 
from the fubjacent pectoral mufcles, that I 
could pufh- my finger, along with the inte* 
guments, fome way behind each mamma-) 
Which felt like a bundle, of enlarged glands 
connected together. This detached ftate of 
the breads rendered the operation neither 
difficult, nor tedious. I left a confiderable 
portion of the integuments to cover the part 
from whence the bfeait was removed; and 
my patient recovered without any bad fymp* 
toms-. The breaft, after amputation, weighed 
eleven pounds four ounces avoirdupois. 

The operation was attended with a fuccefs 
that exceeded my expectation. Menftrua-* 
tion foon returned, and became regular. A 
diminution of fize in the right mamma was 
in a ihort time apparent; and during an 
attack of fever, which (he had about fix 
months after her discharge from the Infirma- 
ry, the diminution became confiderable. 

She is now a healthy young woman, and 
at the time of writing this, twenty-three. years 
Oi age. The right breaft is ftill larger than 



Enlargement of the Mammae. 485 

is natural; but it is not half fo large as it 
was before the amputation of the left breaft. 
The integuments covering the right breaft 
are in a loofe flabby ftate, and the breaft itfelf 
does not feel like one compa6l gland, but, 
as was mentioned before, like a number of 
glands connected. A curvature in the fpine 
ftili continues; but me is become ftraighte? 
than (he was before the operation* 



IlJ 



[ 486 ] 



CHAP. XVII. 



Or Collections of Pus in the Vagina, 



C A S E . I. 

IN April, 1780, Mrs. D. of S. about 
twenty miles from Leeds, confulted me on 
account of a very troublefome jluor albus, 
as ill e judged it to be. She informed me, 
that the diforder had come upon her about 
five years before, during pregnancy, and had 
hitherto refilled the effect of every remedy 
given for her relief. In anfwer to my inqui- 
ries fhe gave me the following account of her 
complaint. 

The colour of the difcharge was white, in- 
clining to yellow. It flowed in an irregular 
manner, unconnected with any circumftance 
which fhe could recollect. Sometimes the 
discharge ceaftxl entirely. Sometimes it be- 
gan to flow fuddenly in large quantity, and 
continued dimiriiftiing until it ccafed. The 

parts 



Of Collections of Pus, &c. 48/ 
parts were often rendered fore by the eva- 
cuation. 

From thefe circumftances I fufpeoted, that 
the nature of the complaint had been mif- 
ftaken ; and was apprehenfive that a collec- 
tion of purulent matter might have been 
formed in the vagina, I gave her the rea>- 
fons of my fufpicion; and told her, that, in 
my opinion, the true ftate of her cafe could 
not be afcertained without an examination of 
the part affected, 

Upon examination my fufpicions were ve^ 
rified. I found a quantity of purulent mat- 
ter colle&ed on the left iide, where the la- 
bium pudendi joins the vagina. I thruft the 
blunt end of a probe into the cyft, where it 
appeared to be very thin, and the matter 
flowed out copioufly. I informed her, that 
a furgical operation would be neceffary for 
her cure; but {he declined fubmitting to it, 
and returned home. 

I heard no more of my patient till May 
1781, when me returned to Leeds, deter- 
mined to put herfelf under my care. The 
diforder had remained in the fame ftate. The 
cyft was fometimes healed; and then, burft* 
ing open, continued for a time to dilcharge 
the purulent matter, as before* 

J l 4 Upon 



■488 Op Collections of Pus 

Upon dividing the cyft, I found that the 
cavity in which the matter lodged, was about 
an inch and half in diameter. The whole 
interior furface of the cyft was fmooth and 
ihining; and on that account I judged it 
improbable that a fimple divilion of the cyft 
would effe6t a cure. I thought it necefTary, 
therefore, to remove the greater part of that 
portion of the cyft which was formed by the 
internal lining or cuticle of the labium pu- 
dendi. The haemorrhage was inconfiderable, 
and foon ceafed. The wound healed kindly, 
and my patient obtained a perfect cure. 

CASE II. 

In 1786, Anne Miller came under my 
care as ah out-patient of the General Infir- 
mary at Leeds, for a node upon the tibia, 
which I fulpecled to have had a venereal 
origin. When fhe was about to be difcharged 
cured, me informed me, that fhe had been 
troubled for fifteen or fixteen years with fud- 
den and irregular difcharges of purulent 
matter from the vagina. Thefe difcharges, 
fhe faid, were frequent, and fometimes con- x 
.iiderable; yet fhe never perceived any matter 
to he mixed with her urine. 

9 Upon 



in the Vagina. 489 

Upon examination I found a roundiih 
tumour at the os externum, appearing to be 
formed by an enlargement of the bulbous 
part of the urethra. When the tumour was 
compreffed, pure pus iffued from the ure- 
thra; yet her urine, when drawn off with a 
catheter, did not contain the leaft mixture 
of purulent matter. Upon introducing a 
bent probe into the urethra, I could eafily 
pum it to the mod depending part of the 
tumour; and could feel the probe diftincily 
by a finger introduced within the vagina. 

I divided the tumour longitudinally, at a 
time when it was diftended with matter. That 
part of the vagina which I cut through was 
not thinned by the distention, but was rather 
tough. The cavity of the cyft was fmooth, 
As the opening which I had made was de- 
pending, and as the removal of any part of 
the cyft would have been attended with 
difficulty, I only filled the cavity with lint. 
A. fmall artery was opened by dividing the 
cyft, but the haemorrhage' did not continue 
long. This patient recovered fpeedily, and 
got quite free from the complaint. 



[ 490 ] 

chap, xvfir. 
On Alvine Concretions, 



SO many hiftories have been publifhed of 
Alvine Concretions, which had acquired a 
form fomewhat globular, generally contain-* 
ing a nucleus of fome hard and indigeflible 
fubftance, as the ftones of fruits, &c, that 
it may feem unneceffary to relate more in* 
fiances of this difeafe. 

Yet, as this work may fall into the hands 
of fome perfons, who have not read the hif- 
tories to which I allude; and as the public 
can jcafcely be too often reminded of the 
impropriety of fwallowing the ftones of plums 
or cherries, which young people eipecially 
are apt to do in eating thofe fruits ; I fhall 
give one inftance of the dangerous, and ano- 
ther of the fatal effefit of thefe concretions* 

C A S E I. 

I was defired fome years ago to vifit a 
young woman* who complained of great pai$ 

m 



I 



Ox Alvine Coxcretioxs. 491 
in the hypogaftrium, and at the anus, at- 
tended with difficulty of difcharging her 
feces. The preflure which me felt occafion- 
ally at the anas was fo great, that I judged 
it neceffary to examine that part, and found 
a hard fubftance preffing againft the fphin&er 
ani, which ilie could not expel by the natural 
efforts. 

I extracted this fubftance by means of a 
pair of forceps ufed in lithotomy, and found 
it to be a ball of light friable matter, con- 
taining a rough plum-ftone in its centre. 
After this was removed, two other concre- 
tions of the fame nature prefented themfelves, 
and were extracted in fucceffion by the fam$ 
inftrument. They had each of them a plum- 
ftone for a nucleus. 

Upon inquiry into the origin of this young 
woman's complaint, there feemecl no reafon, 
to doubt, that thefe ftones had remained fix 
years in the alimentary canal. The young 
woman recollected having paid a vifit to an 
uncle, who was a grocer at Wakefield, and 
who had permitted her to eat freely of prunes 
in his (liop. She remembered alfo having 
frequently fwallowed the ftones of the prunes 
which (lie then ate. But fix vears had now 
elapfed fince this vifit; and me was pofitive* 



492 On Alvine Concretions. 

that flie had not eaten a prune iince that 
time. 

Thefe concretions may" grow to fuch a 
bulk, that they cannot pals into the rectum, 
and of confequence muft prove fatal to the 
patient, as in the following cafe, 

CASE II, 

I was permitted to examine the body of a, 
boy, whofe parents lived at Holbeck, near 
Leeds, and who had died in an emaciated 
ftate, having had long continued pain in the 
abdomen, attended with frequent attacks of 
the ileus. 

I found a concretion, of the kind above 
mentioned, lying in the tranfverfe arch of 
the colon, which was become of fo great bulk, 
that it could pafs no farther along the courfe ' 
of the interline. This feemed to have been 
the fole caufe of the boy's death. 

Mr. White, of Manchefter, has publiflied 
fome ufeful cafes of this difeafe, and has alfo 
given references to other authors, who have 
treated on the fame fubjecV* 

An inftrucYive paper, written by the late 

* See Cafes in Surgery, by Charles White,, J\ 11. S. p. 17« 

Dr, 



Ox Alvine Concretions. 493 
Dr. Fothergill, was publifhed by the MecUcat 
Society, in the 3d vol. of Medical Obferva- 
tions and Inquiries, p. 123, on the collection of 
indurated faeces in the rectum, which I would 
recommend to the perufal of the young prac- 
titioner^* the difeafe dees not very frequently 
occur, and as it appears under a form fo falla- 
cious, that a perfon, who is not attentive to 
every fymptom, may readily be milled. 

My principal defign in taking notice of 
this difeafe was, to relate a cafe, which, whe- 
ther we regard the hiftory of the fymptoms, 
or the method of cure, will not, I hope, be 
thought uninftrucYive* 

CASE III. 

Mrs. S. was delivered of her third child* 
January 31 ft, 1799. She had not com- 
plained of any unufaal coftive nefs; nor, in- 
deed, had fhe made any complaints to rue 
during the laft month of her pregnancy. 

She had natural evacuations during the firft 
week of her confinement, and took no medi* 
cine except one anodyne draught. At the 
expiration of the firft week, ihe began to 
complain of a painful motion to make water. 

This 



494 On Alvine Concretions* 

This complaint was relieved by giving her 
(Feb. 9th.) a folution of the bitter purging 
fait, and an oily emulfion. She took no 
medicines from this time till the 21 ft, three 
weeks after her delivery, when ihe took a 
purging draught, and fome more of the 
emulfion. She was not now confined to her 
room, nor even to the houfe; but fometimes 
walked out into the garden. 

In the laft week of February the complaint 
became more troublefome and conftant. She 
had frequent pains, exactly refembling thofe 
of labour, attended with a confide rable de- 
gree of pre ffure downwards. Purging draughts, 
laxative clyfters, together with the oily emul- 
fion, and occafionally an anodyne at bed-time, 
afforded her fome relief. Her pulfe, however, 
became more frequent, and a degree of fever 
remained conftantly upon her. 

During the month of March fhe was chiefly 
confined to her chamber, as walking feemed 
to increafe the preffiire downwards* She took 
the fimple faJine draughts, and fometimes 
aa opening draught; but the evacuation of 
the feces was principally affifted by the in- 
jection of mild clyfters- In the laft week of 
this month, the nurfe found the clyfters did 

not 



On Alvine Concretions. 405 

foot pafs into the inteftines as ufual, but re* 
turned immediately. A folution of the bit- 
ter purging fait was, therefore, given more 
freely, but it did not anfwer as ufual; and 
before the termination of the week, a com- 
plete obftruftion in the alimentary canal took 
place. She now began to rejeft by vomiting $1 
what was taken into the ftomach; and there ' 
was an evident fulnefs in the abdomen, par- 
ticularly in the hypogaftrium, which had not 
before been perceived. 

As the nurfe had failed in her attempts to 
inject the clyfters as ufual, and as purgatives 
taken by the mouth were now rejefted, it 
became neceffary to make the ftri£left enquiry 
into thecaufe of this obftruftion. I attempt- 
ed to give my patient a clyfter, *but found 
the fame difficulty of which the nurfe had 
complained. The pipe paffed readily into 
the reftum, and was not blocked up bv 
feces; yet the clyfter returned immediately, 
without paffing into the colon, whatever force 
was ufed in the inje&ion. 

Upon introducing my finger into the rec- 
tum, I found it empty; but its higheft part 
was clofed, being prefled againft the os sacrum 
by a hard fubftance, which occupied the 
fuperior part of the pelvis. This fubftance 

felt 



496 On Alvine Conchet iotf$* 
felt like an enlarged uterus; enlarged, I mean* 
when considered in its unimpregnated ftate* 
I made an examination alfo -per vagi nam, and 
was ftill led to think* that the uterus was 
preffed againft the os facrum. v 

At this period of the difeafe Dr. Davifon 
was confulted, who continued to attend with 
me during the remainder of our patient's 
indifpofition* We gave various purgatives, 
as oL ricini, jalap alone, or with the addition 
of calomel, in the form of pills, magnefia, 
with lemon juice taken immediately after it. 
Thefe medicines fometimes remained for a 
few hours upon the floniach*, but were al* 
ways fooner or later , rejected. A warm 
femicupium was ufed, which afforded fome 
relief from pain, but did not procure an 
evacuation of the faeces. 

Our patient was now reduced to a ftate of 
extreme danger. Purging medicines afforded 
no relief, and clyfters inje6ted into the rec^ 
turn could not be made to pafs the ftri<5iure 
at the brim of the pelvis. In this dilemma 
it occurred to me, that if I could make a 
long flexible catheter pafs beyond the com- 
preffed part of the rectum, I fhould be ena- 
bled to injecl a clyfter through it into the 
iigmoid flexure of the colon, and thereby 

probably 



On Alvine Concretions. 497 

probably bring down the obftru&ed feces. 
To effect this purpofe, I introduced the fore- 
finger of my right hand as high in the rec- 
tum as poffible, and with this finger directed 
the catheter to that part where there feemed 
to be the leaft refiftance. I then pufhed on 
the catheter with my left hand, and with 
my finger which was in the rectum. By this 
method, though not without difficulty, I made 
the inftrument pafs into the figmoid flexure 
of the colon, into which I now injected a 
large clylter. When the catheter was with- 
drawn, its extremity appeared to have pafied 
into fome indurated faeces; which circum- 
ftance not only threw light upon the nature 
of the difeafe, but alfo afforded us . ftrong 
hopes of being able to fubdue it. An evacua- 
tion of faeces was procured, and the vomiting 
ceafed. 

The clyfters were repeated, by the method 
above mentioned, morning and evening, fo 
long as they appeared to be necefTary . They 
were generally made with a pint of water- 
gruel, and an equal quantity of olive-oil, mixed 
by means of the yolk of an egg. The feces 
were fometimes difcharged in hard lumps, 
but they had generally the appearance of 

K k bran, 



498 On Alvine Concretions. 

bran, as if they had become dry by their 
long refidence in the inteftine, and had after- 
wards become mixed with the more liquid 
excretion of the inteftines, or with the clyfter. 
This kind of excrement continued to come 
away during the courfe of a fortnight. 

In the fecond week of April a fpontaneous 
diarrhsea took place, and our patient became 
very feeble. She had now and then a retch- 
ing, which feemed to arife from mere debility 
of the ftomach. Anodynes, with tonic and 
cordial medicines, were now given. Wine, 
or a little brandy, was put into her gruels, 
which were made with fago, tapioca, falop, 
and the like. 

Mrs. S. had at this time a cough, which 
was troublefome. The matter expectorated 
was mucous, and we hoped that it arofe merely 
from too copious a fecretion of that fluid, 
without any ferious affection of the lungs. 

Though the original diforder had been 
completely removed, the fecondary complaints 
which fupervened, attended with general debi- 
lity, brought our patient again into imminent 
danger. Though the diarrhoea was in acon- 
fiderable degree reft rained, yet fhe became 
more and more emaciated, and that to a very 

high 



On Alvine Concretions. 499 

high degree. The quantity of food which 
lhe took was fmall, and her digeftion feemed 
languid. 

In this ftate, April 28th, Dr. Davifon 
propofed the application of a blifter to her 
ftomach, with the view of roufing the action 
of that important organ, and affording a 
general ftimulus to the habit. This feemed 
to have a good effect. We found her not 
quite fo low the next day. From that time 
lhe continued to recover, though flowly ? an(J 
at.laft regained perfect health. 



SK2 



[ 500 ] 



CHA P. XIX. 
On the Atheroma 



THE Atheroma is an ericyfted tumourv 
containing a fubftance refembling foft curds** 
It is fituated immediately under the cutis; 
and the attachment of its cvft to the circum- 
jacent adipofe membrane is generally flight. 
It frequently attacks the face in children, 
forming tumours about the fize of a pea, 
which are fmooth, and appear rather whiter 
than the reft, of the fkin. Thefe after fome 
time become inflamed, and burft. Their 
contents are then difcharged, and the part 
heals without any inconvenience. From this 
fpontaneous termination of the complaint, 
tfiefe tumours are ufually left to take their 
courfe, and are conlidered as of little confe- 

■■* A$EfUfta eft tumor concolor, doloris expers, in quo 
illiquid pulticulae, qua? ccSygtz vocatur, fimile, tunica 
quadam. membranofa concluditur. 

Gorraei Definitiones Medics, p. 8. 

quence. 



On the Atheroma. 501 

quence. When, however, they are iituated 
on the eyelids, (which they often attack) 
and particularly near the eye-laflies, they 
fometimes, during their inflamed ftate, pro^ 
duce a troublefome ophthalmy, which I have 
feen terminate in an opacity of the cornea. 
It is of confequence, therefore, to know the 
proper treatment of this complaint, and the 
following defcription of an eafy method of 
cure may not be unacceptable to the young 
practitioner, 

If the eyelid is the part affected, I make 
an inciiion acrofs the tumour in the courfe 
of the fibres of the orbicular mufele; and, 
after preffing out the contents, I pull out the 
cyft with a pair of differing forceps.. It is 
often difficult to diftinguifti the cyft from the 
cutis, when the tumours are fmall; but by 
preffing the points of the forceps againft the 
fides of the cavity, whence the curdy matter 
iffues, one may foon lay hold of fome part 
of the cyft f Its attachment to the furround- 
ing cutis and membrana adipofa is fo flight, 
that it is drawn out without difficulty. It is 
fometimes broken in the extraction; but one 
may readily difcern whether any part of it 
remains unremoved by the following crite- 

JCK 3 rion. 



502 On' the Atheroma. 

rion. So long as any fragment is left, the 

appearance of tumour continues; whereas 

when the whole is extracted, the tumefaction 

vaniflies entirely. No other dreffing; is ne- 

ceffary in this cafe than a little emplaftrum 

lithargyri. 

If this operation is delayed till the cyft 
has burft, and the tumour, being large, has 
remained in a ftate of inflammation for a 
week or two, a fundus will fometimes be found 
within the tumour, which may require the 
application of the lunar (or fome other) cauftic. 

Atheromatous tumours are often found 
upon the head of adults. I have feen the 
fcalp almoft covered with them. The cyft, 
in this fituation of the tumours, becomes 
firm, refembling a bladder in texture and 
thicknefs. If the tumour is not large, the 
cyfk may be removed whole, by laying hold 
of it with a hook, after making; a crucial in- 
cifion through the fkin, and feparating it 
from the upper part of the cyft. 

When thefe tumours are iituated on the 
eyelids, they ought to be removed before 
they become inflamed, if an opportunity of 
doing this is afforded; but a ftate of inflam- 
mation fhould not be confidered as an im- 
pediment 



On the Atheroma. 503 

pediment to the operation, efpecially if the 
conjun6liva partakes of that ftate. I have feen 
a dangerous ophthalmy fubfide immediately, 
upon the removal of the cyft of an inflamed 
atheroma, fituated upon the edge of the 
eyelid. 



K K 4 



[ 504 ] 



CHAP. XX. 

! lSr DEEP-SEATED A.BSCESSES 

in the Mamma. 



THE abfcefs, which I mean to defcribe^ 
does not frequently occur, yet it is not con^ 
fined to women in the puerperal ftate, nor 
to thofe who give fuck. I have feen it re- 
peatedly in unmarried women. It does not 
differ in its original formation from a common 
abfcefs; but its fituation renders all fuper- 
ficial applications ineffectual, and requires a 
more fevere method of cure, than that which 
is ufually fufficient in the common milk ab- 
fcefs. The inflammatory ftage is tedious; 
and, when the purulent matter has burft 
through the integuments, the difcharge con- 
tinues without any apparent tendency to heal- 
ing. Sometimes the matter burfts out at 
different places, and the intermediate parts, 
of the breaft feel hard, as if_ affected with 
fchirrus. Sometimes the matter lodges behind 
the mamma, as well as in the fubftance of 
that gland. The cavities formed by the 
patter are often numerous, running in a 

variety 



Abscesses in the Mamma. 505 

variety of directions, and, when opened, are 
found to be in part filled with a foft fungus 
of a purple colour. 

This difeafe will fometimes continue for 
many months with little variation in its ap- 
pearance. A degree of heclic fever, how- 
ever, is kept up by the abforption of the 
confined matter; and the breaft ufuallv be- 
comes more indurated in proportion to the 
continuance of the complaint. I have not 
hitherto met with any cafe, which has not 
been cured without extirpation of the breaft. 
The following treatment has always proved 
fuccefsful, and has fometimes efFecled a cure 
in lefs time than the extent of the wounds 
led me to expecl:. 

Having examined the courfe of that fin us, 
out of which the matter iffues, I divide it 
throughout, however deep its fituation in 
the breaft may be. I then examine care- 
fully with my finger the whole extent of the 
wound, that I may difcover the orifices of 
any other iinufes connected with it. Thefe, 
it is necefiary to obferve, cannot always be 
difcerned with the eye, as they are fome- 
times filled up with the foft fungus above 
mentioned, ^and prefent no vifible cavity. 
By preffing the finger upon any part that 
feels fofter than the reft of the wound, one 

may 



506 On beep-seated Abscesses 

may eafily break down the fungus, and there- 
by difcover the orifice of any collateral finus. 
All the finufes muft be opened through their 
whole extent, however numerous, or tortu- 
ous in their courfe. Unlefs this be done, 
the operation proves fruitlefs. If, in doing 
this, I find any two finufes running in fuch 
directions, that, when fully opened, they 
leave a fmall part of the mamma in a pen- 
dulous ftate, I remove that part entirely. 
I have been under the neceflity in this oper- 
ation of making fo many incifions through the 
breaft, that it has been divided into feveral 
pieces, yet the wounds' have healed favour- 
ably, and the breaft has ultimately preferved 
its natural figure. This operation has fuc- 
ceeded in habits which would be judged un- 
favourable to the healing of any wound, as 
in the following 

CASE. 

Martha Wilfon, of PontefracT:, was admit- 
ted an in-patient of the General Infirmary, 
on account of fcrofulous ulcers. I fcarcely 
ever faw them fo numerous in any oneperfon. 
The anterior part of the thorax, the clavicle, 
the moulder, and axilla on the left fide, were 
almoft covered with them. After having 
obtained confide rable relief by the ufe of 

the 



in the Mamma. 507 

the lotion mentioned below*, by which moll 
of the fuperficial ulcers were healed, (the 
incruftations, which covered them at her ad- 
miffion, being removed by a digeftive oint- 
ment) fhe was made an out-patient. While 
fhe remained at home, a deep-feated abfcels 
was formed in, and behind, the mamma. 
After this had continued fome months {he 
was again taken into the houfe. The matter 
had burft through the integuments juft above 
the mamma. A probe, introduced at this 
orifice, paffed down behind the breaft, till it 
might be felt through the integuments below, 
I made a complete divifion of the breaft, and 
alfo opened three lateral finufes, which com- 
municated with the longitudinal one, but were 
not of great extent. Notwithftanding the ha- 
bit of this patient, the wounds healed fo fpee- 
dily, that an union of the divided parts was 
formed in the courfe of a fortnight, and the 
wounds were cicatrized in a fhort time after- 
wards. The proper form of the mamma was 
preferved, 

# $. Aquae purae, Jxxx: 

Spt. Rorifmarin. Jij. 
- - - Lavendul. com p. 3y. 
Zinci vitriolati, 3j. 
mifce fiat, lotio. , 

The ulcers were kept continually moiftened with this 
lotion, by the application of folded linen cloths prer 
vioufly foaked in it. 



508 



€ H A_ P. XXI. 

On Amputation; 



DISEASES which require the amputa- 
tion of a iimb, or fome part of the extremi- 
ties, fo frequently occur, that every improve- 
ment of this operation muft be conlidered as 
important in the practice of furgery. The 
method of amputating fo as to heal the wound 
bv the firft intention, as it is called, I conn*- 
der as a capital improvement; and am forry 
that it is not yet univerfally adopted. If I 
were not aware of the force of prejudice, I 
fhould be ready to conclude, .that a furgeon 
was defective either in knowledge or huma- 
nity, who did not prefer this method, when- 
ever it was in his power to make ufe of it, 

A cure is performed by it in one-fourth 
part of the time which is required when the 
ordinary mode of dreffmg is ufed, The 
pain fubiequent to the operation, which is 
great and long continued when the interior 

parts 



Otf Amputation. 509 

parts of the wound are dreffed, is herebv 
avoided in a great meafure ; and the cica- 
trix, which muft remain in fome degree after 
the wound is healed, being reduced to a very 
fmall breadth, is not fo liable to break open 
again from accidental injuries. This method 
of operating, when rightly underftood, is 
not peculiarly difficult; but the comparative 
relief which the patient receives from it is 
great indeed. 

1. Amputation in the Thigh or Arm. 

When a flap is not made, which is ufually 
unneceffary when amputation is performed in 
the thigh or arm, nothing more is neceflary 
than to amputate with a triple incifion, and 
to preferve fiich a quantity of mufcular flefti 
and integuments, as are proportionate to the 
diameter of the limb. By a triple incifion 
I mean, firft, an incifion through the integu- 
ments alone; iecondly, an incifion through 
all the mufcles made fome what higher than 
that through the integuments; and thirdly, 
another incifion through that part of the 
mufcular flefli which adheres to the bone, 
made round that part of the bone where the 
faw is to be applied. When thefe incifions 

are 



510 On Amputation. 

are made in their proper places, the integu- 
ments and mufcles on the oppoiite fides of 
the ftump will meet each other conveniently, 
and may be preferved in conta6i fo as to 
produce a fpeedy healing of the wound, and 
a convenient covering for the extremity of 
the bone. 

The proper diftances of thefe incifions from 
each other muft be determined by the thick- 
nefs of the limb, upon which the operation 
is to be performed, making allowance for the 
retraction of the integuments, and of thofe 
mufcles which are not attached to the bone. 

I will fuppofe the operation to be performed 
upon the thigh, and the circumference of the 
limb to be twelve inches, at that part where 
the divifion of the bone is intended to be 
made. The diameter of the limb, in this 
cafe, being four inches, if no retraction 
of the integuments were to take place, a 
fufficient covering of the ftump would be 
afforded by making the flrft incifion at the 
diftance of two inches from the place where 
the bone is to be fawn, that is, at the diftance 
of the femi-diameter of the limb on each fide. 
But as the integuments, when in a found 
ftate, always recede after they are divided, 
it is ufeful to make fome allowance for this 

receffion ; 



On Amputation. 511 

receffion ; and to make the firft incmou 
half an inch below the femidiameter of the 
limb. 

Suppofing the thicknefs of the Integuments 
to be half an inch, the diameter of the limb 
after the firft incifion would be reduced to 
three inches ; the fecond inciiion might, there- 
fore, be made at the diftance of an inch and 
half below T the place where the bone is to be 
divided: but it is ufeful to make fome allow- 
ance for the retraction of the mufcles, par- 
ticularly the pofterior mufcles of the thigh, 
which takes place in them to a coniiderable 
degree in the procefs of healing. Thefe 
mould be divided fomewhat lower than the 
reft of the mufcles, if it is wimed that the 
mufcular flefti mould retract equally on all 
fides of the ftump. The divifion of the pof- 
terior mufcles may be begun at half an inch, 
and that of the anterior at three quarters, 
above the place where the integuments were 
divided. The integuments will retracl a 
little both above and below the place where 
they were divided; but the diPcance from 
that place muft be computed from the mark 
left upon the furface of the mufcles in divid- 
ing the integuments. The edge of the knife 

mould 



5112 On Amputation". 

mould be directed fomewhat obliquely up- 
wards in dividing the mufcles, and the divifioi? 
mould be made through the pofterior mufcles 
at one ftroke, and through the anterior at 
another. 

In order to make the third incifion, the 
divided integuments and mufcles muft be 
drawn upwards by an affiftant, who will ge- 
nerally do this the moft conveniently with 
the aid of a retra&or,- and who mould be 
cautious to avoid pulling the periofleum from 
the bone, when the mufcles which adhere 
to it are divided. 

The moft perfect union of the foft parts* 
would be produced by making an incifion 
through them all in a conical direction ; the 
apex of the cone being that part of the bone 
where the faw is to be applied. But fuch an 
incifion is impracticable in the ordinary mode 
of operating; nor is it neceffary for the for- 
mation of a good flump.* * 

As 

* It is evident, that a conical inciiion through the 
mufcles of the thigh cannot be made with a continued 
itroke, in the ufnal mode of amputating. For fuppof- 
ing the edge of the knife to have once penetrated ob- 
liquely through the mufcles, fo as to be an inch higher, 
when arrived at the bone, than when it penetrated the 
5 » furface; 



On* Amputation* 513 

As it is defirable that the ligatures, by 
which the bleeding veffels are fecured, fhould 
be call off in the courfe of ten or twelve 
days, it is the beft method to draw out the 
extremity of each veffel with a tenaculum, 
for the purpofe of applying a ligature. But 
the fituation of an artery is often fuch, that 
it becomes neceffary to make ufe of a needle. 
In this cafe, the needle (liould be made to 
pafs as near the veffel as poffible. I have 
been accuftomed to tie the femoral artery 
twice, leaving a fmall fpace between the li- 
gatures; and this method has been conftantly 
ufed in the Leeds Infirmary fince its eftab- 
lifhnient. Having feen a few inftances of 
bleeding from the femoral vein, I generally 
inclofe the vein in the ligature along with the 
artery. 

I have feen a few inftances of the integu- 
ments becoming -fo contracted after the oper- 
ation, as to comprefs the veins juft above the 
extremity of the flump, and bring on after 
fome hours a copious haemorrhage. When it 
has appeared clear to me that the haernor^ 

furface; if the incifion be Continued with a flowing 
itroke, the knife mult then cut the furface of (lie undi- 
vided mufcles an inch higher than at the commence- 
ment of the incifion* 

L & rhage 



514- On Amputation. 

rhage was venous, I have made a divifion' of 
the integuments on one fide of the thigh* 
fufficient to remove the ftri6ture, and this 
method has immediately fuppreffed the hae- 
morrhage. Should the integuments, after 
amputation, mew fuch a difpofition to con^ 
traft, as to threaten a ftrangulation of the 
ftump, (a cafe which I have feen) it is then 
prudent to make a longitudinal divifion on 
one fide of the ftump before the dreffings are 
applied, and to continue it fo high as to 
remove all appearance of undue contraction . 

Sometimes the integuments of the thigh 
are in a morbid ftate on one fide of the limb, 
while they are found on the other. In this 
cafe, a longer portion of integuments and muf- 
cular fleih muft be left on the found fide, 
which will not prevent the formation of a 
good ftumo. The morbid ftate of the an- 
terior or pofterior fide of the thigh fome limes 
extends fo far above the knee, that it is ad* 
vifable to amputate with a flap. I have 
feveral times, indeed, made a flap on the 
anterior part of the thigh by choice, though 
I do not ufually operate in this way, as it 
umieceffarily fliortens the remaining part of 
the limb. I have never, but from neceffity,, 
made a flap on the pofterior fide of the thigh, 
2 , yet 



On Amputation. 515 

yet this may be done in certain cafes with 
great advantage. 

A brother of the ingenious Mr. Mann, of 
Bradford, near Leeds, the inventor of the new 
artificial wooden leg, had an enlargement of 
the inferior and anterior part of the thigh- 
bone, which required the amputation of the 
limb. The pofterior part of the thigh being 
in a perfe6tly found ftate, I made a flap of 
the integuments and mufcles on that fide* 
and by this method w r as enabled to faw off 
the bone immediately above the tumour, 
which in this cafe was a great advantage. 
The tumour, upon diffe&ion, was found to 
be principally cartilaginous, though the pro- 
cefs of offification had begun in it, and 
Teemed to be advancing from the thigh-bone 
towards its exterior parts. The neceffities 
of a near relation urged both the father and 
brother of this patient to contrive an excel- 
lent fuccedaneum. The contrivance of the 
brother being judged to have fuperior excel- 
lence, a patent was obtained for the inven- 
tion, which has added much comfort to the 
lives of many who have had the misfortune 
to require amputation above or below the 
knee. 

US In 



516 On Amputation. 

In fcrofulous white-fwellings of the knee* 
the facculus mucofus, which lies behind the 
tendon of the rectus femoris, is fometimes in 
a morbid ftate, diftended with a glairy puru- 
lent fluid, and extending fo high above the 
knee, that it would be inconvenient to make 
the incilion through the mufcles above the 
tumour. In this cafe, a furgeon is not under 
the necefiity of amputating with a flap made 
on the pofterior part, of the thigh, if he dis- 
likes this mode of operating : but he mould 
diffeft out that part of the morbid fac which 
remains above the place where the mufcles 
are divided. This operation is practicable; 
and I have always judged it to be prudent, 
left the remains of fo morbid a part mould 
give rife to fome frefti difeafe in the ftump. 

When the limb is amputated, the integu- 
ments and mufcles may be brought into con- 
ta£t by preffing either the anterior and pofte- 
rior parts, or the fides of the thigh, together. 
The former method, by the gradual retraction 
of the pofterior mufcles, caufes the integu- 
ments of the anterior part of the ftump to 
cover more completely the extremity of the 
bone. The latter method caufes the inte- 
guments and mufcles to meet each other the 

more 



Oisr Amputation. 517 

more readily, and therefore is to be preferred 
when the quantity of foft parts preferved is 
fomewhat deficient. 

The integuments are moft conveniently 
held in contact by futures, for the" making of 
which, ftraight needles fliould always be uied. 
But an union of the parts may be produced 
without futures, by keeping them in exact 
contact with the affiftance of plafters. Both 
thefe methods of dreffing have their advan- 
tages and difad vantages, and my opinion has 
fluctuated refpecting their fuperiority. Plaf- 
ters give lefs pain in their application, and 
are more eafily removed and renewed when 
a fubfequent haemorrhage requires the ftump 
to be opened : but they confine the purulent 
matter more within the wound, and thereby 
delay the cure; and fometimes caufe pain 
from the confinement of the matter. Su- 
tures give more pain in the application, and 
that fometimes in a confiderable degree; but 
then, if the amputation has been properly 
conducted, no tight preffure of plafter, nor 
ftrict bandage, is required to keep the integu- 
ments in contact; a long pledget of cerate, 
with a flannel roller, being all the dreffing 
required, till the ligatures of the integuments 

1 l 3 are 



$18 On Amputation. 

are removed. The purulent matter efcapes 
tnore readily through the apertures in which 
the ligatures, of the veffels lie, and the cure 
is generally more fpeedily accomplimed. 
Either method may be ufed after amputation 
made upon the thigh, with the triple incifion ; 
but when a flap is made in the leg, futures. 
are preferable, for a reafon which I fhall 
mention. 

When futures are ufed, the ftraight needles 
fliould be p'uftied obliquely through the inte- 
guments, for the purpofe of bringing them 
more exactly into contact*. 

After the iirft two days, the pledget and 
bandage may be renewed every day ; and as 
foon as the ligatures which united the integu- 
ments become loofe, they fliould be cut out, 
and the parts mould be fupported by plafters. 

It is no fufficient objection to the method 
of healing a ftump by bringing the divided 
parts into contact, without the intervention 
of any other extraneous fubftance, except the 
ligatures which have been applied to the 
arteries, that a haemorrhage may take place 
feveral days after the operation, and even; 
when the integuments are united. This is a 
Tare occurrence, though I have known it to 

happen* 



On Amputation". 519 

happen. However, I know that the repara- 
tion of the integuments by a fcalpel, in this' 
cafe, gives very little pain to the patient; 
and the pofiibilicy of inch an occurrence is 
not to be let in competition with the advan- 
tages of this method of conducting ampu- 
tation. 

When we are under the necefiity of am- 
putating a limb that has fuffered great con- 
tuhon, though the operation is performed 
upon a part apparently found, the wound 
fometimes becomes floughy, and ill-condi- 
tioned. No good granulations arife to cover 
the extremities of the arteries; but the liga- 
tures cut through thefe veffels, or becoming 
loofe, ceafe to make a fufficient preffure upon 
them, and hence repeated haemorrhages en- 
fue. This is a dangerous ftate -for a patient; 
for if the veffels are taken up afrefh with 
the needle, the haemorrhage will now and 
then return in the courfe of two or three 
days. In fuch cafes the application of dry 
fpunge, cut tranfverfely, as directed by Mr, 
White 1 *, has been found Angularly ufeful, 
and has faved the life of the patient. But a 
conftant preffure muft be kept upon the 

* See Cafes in Surgery, by Charles White, F. R. S. 

U 4 pieces 



520 Qn Amputation 

pieces of fpunge, by the fingers of a fucceffiorv 
of afliftants, till granulations begin to arife 
Upon the flump, and the profpefil of future 
haemorrhage difappear. This .method is of 
the greateft. importance after amputation on 
the thigh or leg, where the great veffels are 
deeply feated. In the arm, above the elbow, 
where the veffels are more fuperficial, the 
great artery may be taken up, with a portion 
of mufcular flefh, above the furface of the 
flump, by making firft an incifion through 
the integuments. My colleague Mr. Logan 
has done this twice within the laft year, with 
complete fuccefs, when repeated ligatures* 
applied in the ufual way, had failed. 

In the morbid floughy ilate of the flump 
above mentioned, the application of lint 
foaked in a liquid, compofed of equal quan-^ 
tities of lemon juice and re£lified fpirit of 
wine, has been found very advantageous, and 
has caufed the flump to put on foon a healthy 
afpe6l. 

2- /Imputation below the Knee. 

Amputation below the knee, when a flap 
is preferved, has been ufually performed at 
as fmall a diflance above the ancle as is ne- 

ceflary 



On Amputation. 521 

ceflary for the formation of a flap; but I am 
fatisiied from much experience, that this is 
not the rnoft proper place for amputation. 

Soon after Mr. White had publifhed his 
account of amputating with a flap, as recom- 
mended by Mr. O'Halloran, of Limerick, 
I went over to Manchefter to fee the effect 
of this operation. It appeared to me to be 
a confiderabie improvement in furgery; 
though, from the manner in which Mr. 
White then made the flap, this did not com* 
pletely cover the extremity of the (lump. I 
determined, however, to introduce this me- 
thod of amputating into the Infirmary at 
Xeeds; but before an opportunity offered, I 
was informed of an improvement which Mr- 
Bromfeild had made upon Mr. White's oper- 
ation*. Mr. BromfeikTs manner of making 
the flap feemed Tuperior to that of Mr. White; 
but I approved of the double incifion which 
Mr. White had ufed in fome of his cafes. I 
refolved therefore to combine the improve- 
ments of thefe two eminent furgeons, by 
making the flap in the manner recommended 
by Mr. B. at the fame time preferring, by 
the double inciiion, a portion of integuments, 

* Mr. Bromfeild afterwards publilhed this method. 

on 



522 On Amputation. 

oil the anterior part of the leg, fufficient to 
cover completely the edge of the tibia. 

I operated for the firft time after this man- 
ner March lit, 1772; and* as Mr. Lucas 
has obferved, who fent an account of this 
and fome other cafes to the Medical So- 
ciety in London, ff no onoortunity has been 
u omitted in giving t^e preference to this 
u mode of amputating fmce it was iirft 
ci done*." After Mr. Alanfon, and the other 
furgeons at the Liverpool Hofpital, had made 
a farther improvement of this operation, by 
applying the flap immediately after amputa-r 
tion, we adopted their method in preference 
to that, recommended by Mr. White, of dref-. 
fing the flap and flump feparately till the 
ligatures had fallen off. 

In 1 774, I operated upon James Pilking- 
ton-f, in whofe cafe I was under the neceffity 
of amputating at the lower part of the belly 
of the gaftrocnemius mufcle* I applied the 
flap by degrees, and made a good covering 
for the ftump. I continued 3 however, to 
amputate in general a little above the ancle 
for many years. But fome cafes occurring, 
in which, from a fcrofulous habit, the wound 

* Medical Obfervations and Inquiries, vol, 5.. p. 327. 
f Ibid, 

would 



On Amputation". 523 

would not heal completely, or remain healed, 
fo that the patient could neither bear the 
preffure of a focket, nor conveniently ufe a 
common wooden leg (as the length of the 
limb projecting backwards expofed the ft amp 
to frequent injuries); I determined to try 
whether amputation in a more mufcular part 
of the leg would not fecure a complete heal- 
ing, and give the patient an opportunity of 
refting his knee on the common wooden leg, 
or uiing a focket, as he might find moft convex 
nient. I now prefer this method, and have re- 
duced it to certain meafures, the recital of 
which will beft convey my ideas, and affift thofe 
who wifh to adopt this mode of amputation. 

It had been the general practice at the 
Leeds Infirmary, to make the length of ~the 
flap equal to one-third of the circumference 
of the leg, at that part where the amputa* 
tion was made. But we ufed no meafure 
for the breadth of the flap. This was deter* 
mined by the eye of the operator, who 
ufually pulhed the catlin through the leg, 
near the pofterior part of the fibula. Find* 
ing that I did not always make the flap of 
the moft convenient breadth, I began to aft 
certain this alfo by meafure, and now always 
operate in the following manner. 

To 



524 On Amputation 

To afcertain with precifion the place where 
the bones of the leg are to be divided with 
the faw, together with the length and breadth 
of the flap, I draw upon the limb five lines, 
three of them circular, and two longitudinal. 
The fituation of thefe lines is determined in 
the following manner. I firft meafure the 
length of the leg from the knee to the ancle; 
that is, from the higlieft part of the tibia 
to the middle of the inferior protuherance of . 
the fibula, At the midway between thefe 
tw r o joints I make the firft, or higheft, cir- 
cular mark upon the leg*. This mark is to 
point out the place where the bones are to 
be fawn through. At this mark alfo I raea* 
fure the circumference of the leg, and thence 
determine the length and breadth of the flap, 
each of which is to be equal to one-third of 
the circumference. In meafuring the circum- 
ference of the limb, I make ufe of a piece of 
marked tape or ribbon ^ and place the ex- 
tremity of this meafure upon the anterior 
edge of the tibia. I will fuppofe the circum- 
ference to be twelve inches, in which cafe I 

* Plate ix. fig. I. a a. 

N. B. The continued lines in this figure mark the 
place and extent of the incifions. At the place of the 
doited lines there is no external incifion. 

f Such as are fpld in the (hops in fmall ivory cafes. 

make 



L\ facs Paqt 3 ?J. 



PL. 9. 




On Amputation. 525 

make a dot in the circular mark on each fide 
of the lea:, at the diftance of four inches from 
the anterior edge of the tibia. It is evident 
that thefe dots will be found four inches dis- 
tant from each other, when the meafure is 
applied to the pofterior part of the leg. From 
each of thefe dots I draw a ftraight line 
downwards, four inches in length, and paral- 
lel to the anterior edge of the tibia*. Thefe 
lines mark the courfe which the catlin is to 
take in the formation of the flap. At the 
extremity of thefe lines I make a fecond cir- 
cular mark upon the leg, which points out 
the place where the flap is to terminate *f\ 
Laftly, I make a third circular mark, at the 
diftance of an inch below the fuperior one 
which was firft made J, which intermediate 
mark is defined to direct the circular inci- 
iion through the integuments on the ante- 
rior part of the limb. The courfe and extent 
of the different incifions being thus marked 
out, the operation may be performed with 
the greateft precifion. 

* Plate ix, fig. 1. d. f lb. e e. — The incifion is 
ufually carried to afmall diftance below the inferior cir- 
cular mark, to allow for the retraction of the {kin, which 
is the greateft at its extremity, and to preferve a circu- 
lar border in the flap j but the diftance reprefented in the 
plate is too great. 

% lb. b c. 

The 



526 On Amputation. 

Thd catlin, which is ufed for. the purpofe 
of making the flap, ought to be longer than 
thofe whkh are commonly made for a cafe 
of amputating inflrumenjs. That which we. 
life at the Leeds Infirmary is feven inches 
long in its blade. I prefer a catlin which is 
blunt at the back, as I wifii to avoid making 
any longitudinal wound in the arteries at 
the extremity of the flump* for fuch a wound 
makes it more difficult to fecure them with a- 
ligature. For the fame reafon* I pufli the 
catlin through the leg, a little below the 
place where the tranfverfe incifion is to be 
made of thofe mufcles which are not included 
in the flap. Having placed the limb in a 
poiition nearly horizontal* with the fibula 
upwards* and the knee bent* I pufh the cat^ 
lin through the leg at d* and carry it down* 
wards* along the courfe of the longitudinal 
marks* till it approaches the loweft circular 
mark, which it joins in the courfe of the 
curved line, and the incifion then terminate* 
a little below the inferior circular line e c. 

The flap being held back by an affiflant, 
I divide the integuments on the anterior part 
of the limb along the courfe of the circular 
mark b d. There is always a confiderabl* 
retraction of the fkiu after it is divided* if the" 

integu- 



On Amputation. 527 

integuments are in a found ftate; and if a 
proper allowance were not made for this re- 
traction, the extremity of the tibia would 
he left uncovered, and the flap could not be 
applied with fo much eafe to the patient , 
nor with a certainty of an union by the ad- 
liciive procefs. 

The mufcles, which are not included in 
the flap, are then divided tranfverfely a 
little below the place where the bones are 
to be fawn through; but no great quantity 
of mufcular flefh can be conveniently pre- 
fervecl below the extremity of the divided 
bones (on account of the adhefion of the 
mufcles to the bones), nor. is it neceffary, as 
the flap, when made in the middle of the 
leg, contains a portion of the gastrocnemius 
and fokeus mufcles, fufficient to make a good 
cuihion for the extremity of the bones. 

When the bones are fawn through, it is 
advifable to cut off a little of the extremity 
of the conjoined flat tendon of the gaftroo 
nemius and fokeus mufcles, as it is apt to 
project beyond the ikin when the flap is 
placed in its proper fituation. 

The large crural nerve is frequently found 
lying upon the inner furface of the flap. It 
ihould then always be differed out, and, 

"when 



5£S Oisr Amputation* 

when gently extended, fhould be divided 
iiear the extremity of the ftump. By this 
method it will retire fo far as to fufFer no 
compreffion from the flap. 

I have repeatedly fupported the flap by 
plafters, without making ufe of a needle. 
But although futures are undoubtedly a pain-* 
ful part of the operation, yet, upon the 
whole, I think they contribute to the eafe 
of the patient, when amputation is performed 
below the knee with a flap ; for the flap 
cannot be kept in exacl contact with the fur* 
rounding integuments by means of plafters 
only, without making a confiderable preffure 
upon the end of the bones. And as the fur- 
face of bone, againft which the mufcular 
part of the flap muft be preffed, is here con- 
fiderable; the flap is apt to become inflamed 
by the preffure, and to give the patient more 
pain than when it is united to the integu- 
ments by futures, which keep the flap in fuch 
exafii -contact with the divided mufcles and 
integuments, that there is no occalion for 
ftrong preffure upon it. It is fufficient to 
apply fmall ftrips of court plafter between the 
ligatures, to prevent the ioteguments from 
receding at thofe places, and to fupport the 
flap with a long pledget of tow fpread with 

cerate, 



On Amputation. 529 

■cerate, which is fecured by the flannel roller 
applied to the limb. 

The ligatures, which unite the flap to the 
furrounding integuments* may be cut out on 
the eighth or ninth day after the operation, 
and the flap mull then be fupported by 
platters. 

I fhewed Mr. Mann, of Bradford, a ftump, 
made by amputating in the manner here di- 
rected, and he allured me, that it was ex- 
actly of the length moft fuitable for the ap- 
plication of his artificial leg. Indeed, the 
advantages of a ftump made according to 
the above rules, muft ftrike every one, upon 
the firft view, who is at all acquainted with 
the fubje6l. Mr. Mann advifes all perfons, 
who wifti to avail themfelves of his invention, 
to keep a roller conftantly applied to the 
leg or thigh after amputation, as without 
this previous preffure the limb is apt to 
fhrink, and become fomewhat loofe in the 
focket of his wooden legs*. 

* I lately faw with pleafure a curious arm, the in- 
vention of this ingenious mechanic, perfectly refembling 
a natural arm, and fo contrived, that by a gentle pref- 
fure of it againft the fide of the patient, the fingers are 
made to contract, and lay hold of any fubftance, which 
the perfoa may wilh to grafp. 

Mm 3. Excijion 



530 On Amputation. 



3. Excijion of the Metatarfal Bones. 

The metatarfal bones are fometimes affect- 
ed with caries, while every other part of the 
leg remains found. In this cafe, the removal 
of the difeafed parts may be effected without 
amputation of the whole foot. The remain- 
der of the foot, with the affiftance of the 
ancle-joint, proves of great ufe to the patient 
in walking. When the caries has been con- 
fined to the metatarfal bone of the great toe, 
it has been ufual, I believe, after making a 
longitudinal and tranfverfe inciiion, to faw off 
that part of the bone which has been found 
carious. This, however, cannot well be ef- 
fected without removing a part of the inte- 
guments and mufcles which cover the meta- 
tarfal bone. I have found it to be a more 
convenient and advantageous method of oper- 
ating, to diffefit out the whole of the meta- 
tarfal bone, at its junction with the cunei- 
form bone. A tranfverfe incifion is not 
required in this method;. and as it is not 
neeeffary to remove any part of the integu- 
ments, the wound is more fpeedily healed, 
and the cicatrix is greatly diminiihed. 

The 



On Amputation. 531 

The operation is more difficult when the 
metatarsal bones in the middle of the foot 
are the feat of the difeafe. I have never yet 
attempted to take out a {ingle metatarfal 
bone from the middle of the foot; partly, 
from an apprehended difficulty of taking up 
the bleeding veflfels, in a wound fo ftraitened 
by the contiguous bones of the metatarfus; 
but chiefly, from an uncertainty refpefting 
the extent of the difeafe. When the fmaller 
metatarfal bones have been the feat of the 
diieafe* I have found the integuments on 
the upper part of the foot in fo morbid a 
ftate, that I could not determine* with fatis- 
faclion to myfelf* whether one or more of 
thefe bones had been rendered carious. 
Where only one finus has been formed upon 
the foot, and that leading to a certain bone; 
yet the difeafe has affected the integuments 
to fuch an extent, that it has feemed to me 
imprudent to leave fo much morbid integu- 
ments* as would have been left if one bone 
only had been difle&ed out* Urged by 
the'ie considerations I have judged it to be 
the fafer method (and in this opinion and 
praftice my colleagues at the Leeds Infirmary 
have joined me) to take away all the difeafed 
integuments, by a tranfverfe and longitudi- 

MU 3 nal 



532 Ok Amputation". 

nal incifion, made at right angles to eacli 
other, and then to faw off the -metatarfal 
bones as far as the morbid integuments ex- 
tended. After an operation of this kind, the 
extent of the fore is confiderable ; and as 
no found integuments remain projecting, fo 
as to form } a covering, the cure has always 
been very tedious, and the cicatrix extenfive. 
I was once obliged, in this mode of dper* 
ating, to remove all the toes, except the leaft, 
together with a large portion of their meta- 
tarfal bones. The wound was five months* 
in healing, and broke out again in the courfe 
of a year after the patient was difmifled from 
the Infirmary cured. She was a young wo- 
man, and in other refpefts healthy, yet a 
cicatrix was not completely formed, upon her 
return to the Infirmary, till feveral months 
were elapfed. This operation is greatly fu~ 
perior to that of amputating the leg ; for (lie 
was able, when cured, to walk with very 
little limping. However, the tedioufnefs of 
the cure, and the tendency of fo large a 
cicatrix, on the extreme part of the body, 
to degenerate into a frem fore, afford fome 
objection to this method of operating. 

In the year 1 797, a cafe occurred that led 
me to a new mode of operating, which, upon 

repeated 



0# Amputation. 533 

repeated trial, has fully anfwered my expec- 



tations. 



CASE I. 



Mary Sedgwick, of Otley, aged eighteen 
years, was brought to the Leeds Infirmary, 
on account of an ulcer on the upper part of 
the foot, at the root of the firft and fecond 
toes. Upon examination I found the me- 
tatarfal bones carious. The integuments at 
the root of the third toe being hard and 
dilcoloured, I determined to remove the 
three firft metatarfal bones, and fo. much of 
the fmaller bones of the tarfus as were 
covered with difeafed integuments, My.de- 
fign was to have performed the operation 
in the manner above defcribed; but upon 
fawing the metatarfal bones, they were found 
to be fo foft, that they might eaiily be cut 
with a knife. I did not think it prudent to 
leave any portion of bone that was in fo 
difeafed a ftate, and, in confequence of this 
opinion, I was under the neceffity of removing 
the greateft part of the cuboid bone, which 
fupports the two laft toes, and to faw off 
alfo a fmall portion of the aftragalus. This 
extent of difeafe in the metatarfus and tar- 
fus put me under the neceffity of removing 

m m 3 all 



534 On Amputation. 

all the toes, which were now rendered ufe~ 
lefs, and fuggefted a method of finhhing the 
operation which proved highly advantageous 
to the patient. Having differed out the 
metatarfal bones, and removed the toes, by 
a tranfverfe incifion made at their jun&ion 
with the metatarfal bones; I elevated the 
Integuments and mufcles forming the fole 
of the foot, and applied their extreme edge 
(where I had cut off the toes) to the edge of 
the wound made through the integuments 
and mufcles on the upper part of the foot. 
The 1 parts were retained in contact by fu- 
tures. There was a confiderable difcharge 
from the wound during the firft week ; but a 
firm union afterwards took place , and a part 
of the foot, four inches and a half in length, 
remained completely covered by tfhQ natural 
integuments. 

How far this mutilated foot was capable of 
performing the functions of a natural one* I 
cannot tell, as the poor girl was lame of that 
extremity from other caufes. 

CASE II, 

In the year ] 799, I had an opportunity 
of repeating this operation, and found it to 
anfwer perfectly my expe&atioqs* 



Ok Amputation. 535 

Mary Stansfield, aged eighteen years, of 
Holme in Lancaftiire, was admitted an in^ 
patient of the General Infirmary at Leeds, 
under my care, on account of a caries in the 
metatarfal bones of one foot, upon whom I 
operated in the following manner. 

I made a mark acrofs the upper part of 
the foot, to point out as exactly as I could 
the place where the metatarfal bones were 
joined to thofe of the tarfus. About half an 
inch from this mark, nearer the toes, I made 
a tranfverfe incifion through the integuments 
and mufcles covering the metatarfal bones. 
From each extremity of this wound, I made 
an incifion along the inner and outer fide of 
the foot to the toes. I removed all the toes 
at their jun6tion with the metatarfal bones, 
and then feparated the integuments and 
mufcles, forming the fole of the foot, from 
the inferior part of the metatarfal bones, 
keeping the edge of my fcalpel as near the 
bones as 1 could, that I might both expe- 
dite the operation, and preferve as much 
mufcular flefli in the flap as poffible. I then 
feparated with the fcalpel the four fmaller 
metatarfal bones, at their jun6lion with the 
tarfus; which was eafily effected, as the 
joints lie in a ftraight line acrofs the foot. 

M m 4 The 



536 On Amputation? 

The projecting part of the firft cuneiform 
bone, which fupports the great toe, I was 
obliged to divide with a faw. The arteries 
which required a ligature being tied, I ap^ 
plied the flap, which had forme'd the fole 
of the foot, to the integuments which re-? 
mained on the upper part, and retained them 
in contact by futures. A fpeedy union of 
the parts took place, and the wound was 
healed, except a very fmall fuperficial fore, 
at the expiration of a fortnight. The 'foot 
was not fo much fhortened by this operation 
as might have been expected. For though 
the metatarfal bones, which had been re^ 
moved, are ufually about three inches in 
length*, yet the mutilated foot was^ but 
one inch fhorter than the found foot, mea~ 
fining from the heel to the root of the little 
toe ; the latter being eight inches, and : the 
former feven in length. 

The patient could walk with firmriefs .and 
eafe. She was in no danger of hurting the 
cicatrix, by ftriking the place where th« 
toes had been againft any hard fubltance ; 
for this part was covered with the ftrong 
integuments, which had before conftituted- 

* I dicl not meafure them in this cafe. 

the 



-Z5 Suc&Htgre SS/ 7 . 



PL. 10. 





On Amputation. 537 

the fole of the foot. The cicatrix was fitu- 
ated upon the upper part of the foot, and 
had very little breadth, as the divided parts 
had been kept united, after being brought 
into clofe contaft. The advantages of this 
operation will fufficiently appear upon in- 
fpeeling the annexed plate, in which the 
mutilated foot is accurately represented from 
a drawing made by Mr. Ruffell, of the Royal 
Academy, who happened to be at Leeds before 
this patient was difmiffed from the Infirmary, 
and who favoured me with two views of the 
foot, elegantly painted in crayons. 



TUB END. 



INDEX. 



At anson, Mr. on ftrangulated hernia, page 123, 

yg., ■ ■ ■ improved the flap-operation, 522. 

jilvine Concretions formed on plum-ftones, 490. 

. .1 1. -. - ■ extracted from $he rectum, 49 1 . 

• i , i - . , j ■ from the co!on after death, 492. 

— — Cafes by Mr. White, ib. 

_ — _ _ — by Dr. Fothergill, ib. 

L . ... lodged in the figmoid flexure of the colon, 493— 

499. 
i _ fymptoms of this djfeafe, 494. 

— — . method of cure, 496. 
.!,,< .j.. fucceeded by diarrhaea, &c. 498. 
— - blifter applied to the ftomach, 499. 
Jmaurofis accompanied with cataract, 50. 

■ . ,,,. fucceeding couching, 65. 

■ from inflammation fome weeks after couching, 88. 
Jmputfltion^ advantages of healing by the firfl: intention, 

508. 
— — — In the arm or thigh, 509. 
■ j 1. . ' '., t with a flap made before or behind, 514. 
.. fuccecded by venous haemorrhage, 513. 
-r— — treatment of a difeafed facculus mucofus, 516. 

■ methods of uniting the divided parts, ib. 

■ . ■ fucceeded by haemorrhage after fome days, 518. 
—•— — , by a floughy ftate of the wound, 519. 
1 below the knee, 521. 

m. — 1 , ■ ■ with improved method of mak- 

ing the flap, 521 — 528. 
i . ' , of the metatarfus, 530. 

— — r™ performed twice on the fame limb, 246/ 

Artery 



INDE X. 

Artery tibial^ 31. 

— imperforate after amputation, 246, 

JftragtfluS) part of it cut off in a wound of the ancle, 355* 

■ ■ diflocated, 373. 

Atheroma on the face in children, 50J, 

— producing ophthalmy^ ib. 

— — on the head in adults, 502. 

Bell, Mr. Ben. on ftrangulated hernia, 123, 148. 
Bill am, Mr. ftrangulated hernia, 204, 217. 

■■ ' diilocation of os humeri, 295. 

j" ., ' ■ .. ' ' of the thumb, 326, 

Bougie ufed in retention of urine,, 380, 381. 

p after excifion of cancerous penis, 446, 45?y 

453. 457- 
Brain. On the prefervation of its coverings, 1, &c. fes 

fractures of the ikull. 

— — wounded, 12. 

? fungus arifing from it, 14, 16. 

gs — - concuffion of it, how treated, 469. 

Bromfejld, Mr. reprefTed in the fcapula in a diilocation' 

of the os humeri, 304. 

m ' ■• *.! > • on diflocatioa of the thumb, 325. 

«ss — compound luxation of the ancle, 373, 

e — : — - on perforation of the urethra, 391. 

— — improved the £ap-operation> 521. 

Cancer of the penis y preceded_by a natural phymofis, 445 

—459- 
se — r— — ' by rigidity of the internal membrane of the prepuce^ 

45 6 - 
v accompanied with a tumour above the ofia pubis, 

449. 

1 ? . with enlarged inguinal glands, 454. 

— excifion affifted by tape put round the peni?, 449. 

-— - healing by the firft intention attempted, 452. 

? — — — excifion followed by haemorrhage, 449, 450, 453. 

by contraction of the urethra, 446— ^457 » 

a ' ■ ' — bougies ufed after excifion, ib. 

2 Cancer 



INDEX. 

Cancer of the penis , remarks on the difeafe, 46a. 

Capfule of the cryfiaUine^ fee Cataract, 36, 52, 68, 7c. 

n adhering to the iris, 51, 60, 79, 82. 

.1 fragments of it coalefcing, 86. 

Caque, Monf. on ftrangulated hernia, 186. 

Caries, fee Tibia. 

Cartilaginous fubjlances in the knee, 337. 

Cataract, denned, 36. 

■ ■ ■ difeafe refembling it, 48. 

no certain criteria of its nrrnnefs, 49. 

firm, 49, note. 

foft, 50, 78. 

in one eye only, 52. 

congenital, 53. 

■ from blows, or other external injury, 52. 

complicated with amaurofis or opacity of the 
cornea, 50. 

■ with adhefion to the iris, 51, 79, #6. 

< ' — with lippitudo, 51, 76. 



palling into the anterior chamber, 59. 
once (only) extracted by the author, 74, 
fecondary, 68—70, 91. 
rifing again after depreifion, 66, 90. 



Catheter,, fee Retention of Urine, and Urethra. 
Chiffels, ufed in caries of the tibia, 30. 
Chorley, Mr. 10, note. 

• fee Diflocation, 309. 

Cockell, Dr. invented or revived the ufe of 2 convex 

faw for the cranium, 9, 
Concufjion of the brain, 469. 
Conjunctiva) flaccid, 55, 94. 
Convulfions after ftrangulation, 463. 
Cooper, Mr. of Bungay, 368. 
Couching^ preparation for it, 53. 

operation defcribed, 54 — 63. 

1 to be performed with caution, 71. 

pain of it moderate, 63, 100. 

Couching* 



Cuuchlngy operation does not injure the vitreous humour* 

70. 
* -~~ -r . lefs difficult than extraction, 75. 

■ ' ■ not attended with much uncertainty, 74. 

■ . . ■ . ■ performed in both eyes at the Tame time, 62. 

r fuppofed to detach fometimes a portion of the 
membrana nigra^ 67, 70* 
■■ cataract rifmg again, 66, 90* 

■ operation fucceeded by temporary amaurofis, 65, 
88. 

■ ■ by inflammation, 64. 

— — by pain in the forehead and ficknels, 65,95* 

fuccefsful by making the needle pafg 



through the cataract, 93^ 

- -r - — when the pupil is contracted, 96. 

\'rc , - . ■■ treatment after the operation, 62. 
Coucbing-needle defcribed, 44. 
Craniumj prefervation of, 1, 6—20. 

. deftroying without neceflity by the trephine, ib* 

Cryjialline^ feldom opake at its circumference, 42. 

- 1 its opacity begins at the centre, ib» 

— ' ■ cannot bedeprefled in the polterior chamber, 41* 

m — *>- nor beneath the vitreous humour, 43 

■ adhering to the iris, 51, 60, 79, 82 — 86. 

u ! ' its capfule regaining its tranfparency, 52$ 69, 
82. 
fragments of it coalefcing, 86. 



See Cataracl and Couching. 
Dijlocation of the os humeri, 286. 

— towel ufed in ditto, 287. 

-i ■ — » reduction by gentle extenfion, 285. 
— ... m by the efforts of the patient, 290. 

mi ..1 1 1 ■ . difficult, 292. 

< ■ — method of preventing diflocation, 299. 
... fcapula reprefled by Mr. Bromfeild, 304, 
— — . of os femoris backwards, 312* 



mm of ditto forwards, 315. 

bijiocatign- 



INDEX. 

Diflocatlon of the lower jaw, 322. 

.,- 1 of the thumb, 324. 

Le Dr an on ftrangulated hernia, 128, 145, 178. 

Dura Mater lacerated, 13, 16. 

Earle, Sir James, on catara&, 35, no. 

_— — . on ftrangulated hernia, 202. 

Empyema brought on by the influenza, 477. 

■ fymptoms and operation defcribed, ib. 
* ' five pints of pus difcharged, 478. 

■ medical treatment, 479, 480. 
Else, Mr. fee Strangulated Hernia, 120, note. 
Epiplocele, 219, fee Strangulated Hernia, 
Extrattion of the cataract, fee Cataract Couching.' 
Eye, anatomical remarks on its ftruclurej 37, 40. 

— deductions from that ftru&ure, 4 1 — 43. 

— tremulous motion in the anterior chamber, 70, %0* 

— cry ftal line humour opake, 42, fee Cataract. 

— vitreous humour not injured by couching, 70. 

— pupil contracted, 96, 97. 

Fibula, a portion removed in a wound of the tibial artery, 

3»— 34- 
Ford, Mr. on cartilaginous fubftances in the joints, 337, 

346. 
Erasures ofthefkull, how treated by the author, 1 1. 
— — — — cafes of, 12 — 19, 

— a new law recommended in fuch cafes, 
9 — 16. 

Fungus hamatodes in the thigh, 233, 
1 in the breaft, 254. 

1 in ditto after excifion, 259, 26$, 

■' in the calf of the leg, 268. 

■ in the ancle, 269. 

■ ■ 1 ■■ in the neck, 272, 27^. 

■ on the moulder, 277. 
■ ■ in the wrift, 280. , 
rt remarks on the difeafe, 249, 282—285* 

111 - fketchof a tumour on the arm, 285. 

GlMBERNAT, 



1 NDEX, 

Gimbernat, Don Antonio de, on the femoral hernia, 

Gooch, Mr. applied the trephine thirteen times in a frac~ 

ture of the fkull, 5. 
— propofed the removal of a portion of the fibula^ 

in a wound of the tibial artery, 33. 
["'■"■' on compound luxation of the ancle, 367, 

37 1 * 373- 

-, — — recommended a fteel fupporter for the ancle, 

37*- 

Hernia femoral, defcribed, 151 — 154: 

. fcretal, divided into three kinds, 225, 

, . ; newfpecies, 221, 



congenita, 217, 

. how formed, 223, 224, 

coming on fixteen years after birth, 217, 

infantilis, 221. 

at the navel, fee Exomphalos. 

congenita umbilicalis, 226. 

returning after an operation, 220. 



Hernia Jlrangulated^ 119. 

■ - danger of neglecting it, 120, 141^ 

—144. 
, the parts retiring fpontaneoufly, 12 1* 

— — — — means to procure reduction, 121— 144. 

. — . .. bleeding, 122 — 128. 

— ■ purgative medicines, 128 — 131. 

«- — 1 purgative clyfters, 131. 

■ warm bath, 132—134. 

, opiates, 134. 

. cold (lupes and bath, 135. 

■ injections of tobacco, 136 — 141. 

m . > 1 1 ; ni taxis fucceeds the beft in large hernias^ 

203. 
1 ■ 1 fpeedy operation advifed, 141— 144* 

1 1 - m ■ >■■ operation to be poftponed during the 

ficknefs from a tobacco-clyfter. 

144, note. 

Hernia 



INDEX. 

Hernia Jlrangulatea\ operation defcribed, 145 — 202. 

- fpermatic veffels before the hernial 
fac, 145. 

. tunica vaginalis opened in the opera- 

tion, 147. 

■ operation for the femoral hernia, 148 

— 160. 
■ j inteftines adhering, 160, 182, 208, 

209, 218. 
——————— on one fide of the inteftine, 203. 

■ inteftine thickened, 161, 213. 

— — — gangrened, 162— 1 70. 

1 1 m remarks on gangrene of the inteftine, 

169. 
treatment of the omentum, 170- — 201. 
— — — — inteftines inflamed throughout, 127, 

160. 
' ftrangulated by the hernial fac, 174, 194. 

1 — — by preternatural cords, 209. 

■ . ■ ■ medical treatment after the operation, 

202. 

■ mifcellaneous obfervations, 203. 



Hernial fac, double, 2 11, 216. 

— — contracted at its neck, 174, 194. 

Home, Mr. haemorrhage from the omentum, 199, note. 

Hunter, Dr. on dislocations, 307. 

Hunter, Mr. on hernia congenita, 224, note. 

Inguinal glands enlarged, fee Cancer of the Penis, 454. 

Inteftines inflamed in ftrangulated hernia, 127, 

— — thickened, 181. 

1 gangrened, 161 — 170. 

1 ftrangulated on one fide, 203—207. . 

— — adhering to each other, 160. 

■ — — — to the omentum, 182. 

1 ' — to the peritoneum, 207. 



— ftrangulated by praeternatural cord, 209, fee Stran- 
gulated Hernia. 

N n Jonesj 



INDEX. 

Jones, Mr. fee Diflocation, 295. 
Jfckuria renalis, 377. 

— veficalis, fee Retention of Urine. 

Kirkland, Dr. on diflocation of the os humeri, 293- 
308. 

— — '■" " ' — — of the os femoris, 315. 

Knee-cap ufed, 339 — 341. 

Knee-joint^ internal derangement of, 327—336. 

.. containing cartilaginous fubftances, 337. 

Lippitudo, 51, 76. 

Logan, Mr. 10, note. 

* ■ fee Tibial artery ? 31. 

— — Amputation, 520. 

— — — Fungus haematodes, 285. 

., , , — Dislocation, 310. 

Wounds of the joints, 359. 

Lucas, Mr. fee Cataract, 52, 117. 

■ "■ Strangulated hernia, 209. 

— Diflocation, 287, 302, 

Wounds of the joints, 355, 



- Procidentia ani, 43! 
'imputation, 522. 



Luxation, fee Diflocation. 

Mamma enlarged, 482. 

■7! — — containing deep-feated abfceffes, 504. 

Mann, Mr. inventor of a new wooden leg, 515 — 529. 

-— — ■ of a new artificial arm, 529. 

— "■ ■ — advifes rolling a ftump, ib. 
Medical obfervaiions, 168, 337, 348. 

MlDDLETON, Mr. 345! 

Morgagni, luxation of the os femoris, 307, note. 
Manors, Mr.' on fractures of the fkull, 16. 
Neck, tumour in it, 470.' 
OcuUJls, itinerant, 72, 86. 
Omentum, fee Epiplocele, 219. 

,_ . collected like a rope, 1765 208. 

how treated in the ftrangulated hernia, 160, 170. 

Omentum 



INDEX. 

Omentum left in the hernial fac, 171, 2co. 

adhering to the fac by cords, 175. 

- gangrened, 177. 

fometimes becomes brittle, 178. 

fatal effects of tying i.t, 179. 

■ tied with advantage, 185. 

cut off, 186. 

excifion fucceeded by haemorrhage, 187, 

Opiates, fee Cataract, 65, 96, 10 1. 
■ fee Hernia, 132, 207, 217. 

Os humeri, fee Diflocation, 286. 

part of its inferior extremity cut off, 360. 

— the whole of its inferior extremity removed, 363, 

Penis, fee Cancer of, 445* 
Phymofis, natural, fee ib. 

Pipelet, Monf. on ftrangujated hernia, 179. 
Pott, Mr. his method of treating fractures of the ikull 
examined, 1 — 6. 
'— — on figns of fGftnefs, &c. in the cataract, 49, 52. 

— on bleeding in the ftrangulated hernia, 122. 

on the fafety of the operation in ditto, 141. 

on femoral hernia, 149. 

■ on reducing the omentum before the interline, 

160. 

excifion of the omentum, 170, 187. 

tying the omentum, 179. 



— haemorrhage from the omentum, 187, 196. 

Prepuce, internal membrane rigid, fee Cancer of the 

Penis. 
Procidentia ani in adults, 419. 
» with pendulous flap of integuments, 420 

-438- 

«ri with foft tubercles at the anus, 425, 428, 

441. 
' with haemorrhage, 428, 43Q, 432, 437, 

441, 

N N 2 Procidentia 



INDEX. 

Procidentia ani, with inteftine adhering to the -fphin&er 
ani, 433. 
r . . — - method of cure by an operation, 425— 

43°> 437- 
_ ___ haemorrhage after the operation, 434. 

■ inteftine prolapfed after ditto, 425, 434, 

439- 
— inteftine feparated without exciiion, 438. 

Pulmonary consumption fome'times fucceeds violent haemor- 
rhages, 253. 

Pulfe intermittent in acute difeafes, a %n of faburra in the 
primae vise, 183. 

. not always full and tenfe in inflammation of the in* 

teftines, 206. 

Pupil of the eye contracted, 97. 

. . obliterated, 86. 

■ dilated, 66. 

Pus ^ collection of, fee Empyema and Vagina. 
Reclum, tumour in it, 443, fee Procidentia Ani. 
Retention of urine, defined, 375. 

»— — ■ miftaken for ftrangury, 376. 

* t — ' — for incontinence of urine, 376, 

403—416. 

may confift with a power of making 
water, 437, 401, 402. 

anatomical obfervations, 377. 

method of introducing the catheter, 380, 

382- 

ufe of the flexible catheter, 384 — 399. 
catheter introduced without ftilet, 387. 
bougie ufed, 381. 

effects of withdrawing the catheter, and 
leaving it in the urethra compared, 

399> 403— 4 J 6. 
method of fecuring the catheter in the 
urethra, 400. 

.Retention 



INDEX. 

Retention of urine. Urine fecreted more copioufly in the 

night than in the day, 406, 416. 
' urine ufually high coloured in this dif- 
eafe, 408. 
■ urine bloody, 410, 412. 

—1 delay in introducing the catheter in- 

jurious, 417. 
ReimaRUS de fungo articulorum, 345. 
Russell, Mr. his drawing of femoral hernia, 151: 

■ of the feet after excifion of the 

metatarfal bones, 537. 

Sacculus mucofus above the knee difeafed, 516. 

Saw, a new one recommended, 9, 25, 33. 

Scalps prefervation of it in fractures of the fkull, 4 — 6. 

— removed without fraclure, 6. 

— united by future after fome fractures of the fkull, 17. 
Sharp, Mr. Samuel, judged an uniformly foft cataract 

incurable, 61. 

■ < thought couching lefs difficult than 

extraction, *]%. 



— thought its fuccefs uncertain, 73: 
on firangulated hernia, 159. 



Staphyloma, a confequence of extracting the cataract, 109. 
Stllet of the catheter, 384, 385. 
Strangulation from fufpenfion, 463. 

— — fucceeded by convulfions, ib. 

" ■ ■ relief obtained by wine and tinct. Valer, 

volatilis, 465. 



- warm femicupium ufed, 466. 

fucceeded by languid circulation, 467. 



Strangulated hernia, fee Hernia. 

Tibia, a wedge of it removed with a circular faw, 22—30. 

fee plate 2. 
— abfcefs in it with caries, ib. 
— — perforated by difeafe, ib. 
■ part of it removed by the trephine, ib. 

' — - — — by chiflels, &c. 26 — 30. 

Tibia, 



INDEX. 

Tibia, part of it cut off in a wound of the ancle, 358, 36a. 
' compound luxation of it at the ancle, 368. 

Thompson, Mr. on diflocation, 305— .307. 
Tourniquet does not always completely obftruct the paflage 

of the blood in the arteries, 251. 
Trephine, the only inftrument in general ufed for fawing 

out any portion of the cranium, 6. 

■ its inconveniences, 7. 

ufed in caries of the tibia, 25 — 30. 

Trufs with an oval ring, 172. 

— new one for the exomphalos, 231. 
Tumour in the neck, 470. 

■ — in the rectum, 443. 

•— ^~ _ contents explored by puncture, 475, fee Fungus 

nematodes. 
Vagina, collections of pus in it, 486—489. 

■ cured by an operation, ib. 

Vomiting allayed by brandy in decoction of cinnamon, 2400 
Urethra, its courfe defcribed, 377. 

■ — pouch formed in it, 389. 

— its membranous part perforated, 391 — 398. 

■ injured by contufion, 394. 
Urine, fecretion of, fee Retention of Urine. 

bloody in retention, 410. 

Ware, Mr. on cataracts, 35, 99, 109, in, 112. 

__~ fee Retention of Urine, 384. 

Warner, Mr. on the cataract adhering to the iris, 60, 

61. 
' — - — uniformly foft, 6i# 



' ' his opinion on the fuccefs of couching, 73» 

. — on ftrangulated hernia, 127, 178. 

Wenzel, Baron, on cataract, 35. 

*— — — — his objections againft couching, ex- 
amined, 99 — 1C9. 

■ , .. his allowed confequences of extracting 

the cataract, 109 — 117. 
Wilmer, Mr. on ftrangulated hernia, 123, 126, 178. 

Wounds 



INDEX. 

Wounds of the joints, 349. 

in the thumb, 350 — 352. 

■ in the thumb fucceeded by abfcefTes in 

the arm. ib. 
. ■ in the elbow, 356, 360—366, fet 

Os humeri. 

■ in the knee, 352 — 356. 

1 . ■ - in the ancle, 358. — 360. 



FINIS. 



Luke Hansard, Printer, 
Creat Turnftile, Lincoln's-Inn Fields. 



NEW MEDICAL BOOK& 



LIST OF MEDICAL BOOKS, 

PUBLISHED IN JULY ] 803 ', 
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